Employees Statement Of Exempt Status {DB-130} | Pdf Fpdf Docx | New York

 New York   Workers Compensation 
Employees Statement Of Exempt Status {DB-130} | Pdf Fpdf Docx | New York

Last updated: 6/10/2019

Employees Statement Of Exempt Status {DB-130}

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Social Security #: I (please print full name), at (Place of Employment) an employee of (Name of Employer) residing atdo herby certify that I am now receiving, or am entitled to receive, primary old-age insurance benefits under Title Two of the Social Security Act, and it is based on prior deductions from my own wages. I hereby claim exemption from the provisions of the Disability and Paid Family Leave Benefits Law pursuant to Section 235 for the reason stated above and I waive my right to benefits under the said Law. I further certify that on (date), I filed a signed duplicate of this statement with my employer. Date signed Signed byState of New YorkCounty of}ss On this 20 day of , before me personally cameto me known and known to me to be the person describe in and who executed the foregoing instrument, and duly acknowledged to me that executed the same. Notary PublicTHE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATIONDB-130 (5-19) Prescribed by the Chair, Workers' Compensation Board, State of New York Employee's Statement of Exempt Status Workers' Compensation Board, Disability Benefits Bureau, PO Box 9029, Endicott, NY 13761-9029Annually, eligible employees must reaffirm the Employee's Statement of Exempt Status. Upon receipt of a completed Exempt Status form, the application shall be deemed filed and the employee shall be exempt from withholding for the upcoming rate year. Additionally, in order to maintain an exempt status if you change employment, an Employee's Statement of Exempt Status (DB-130), must be executed and filed with each new employer and with the Chair of the Workers' Compensation Board. Two copies of this form must be completed and signed in the presence of a notary public. Mail one copy to the Workers' Compensation Board and file one notarized copy with your employer. American LegalNet, Inc. www.FormsWorkFlow.com

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