New York > Workers Compensation
Employees Statement Of Exempt Status DB-130 - New York
| Employees Statement Of Exempt Status Form. This is a New York form and can be used in Workers Compensation . |
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State of New York WORKERS' COMPENSATION BOARD EMPLOYEE'S STATEMENT OF EXEMPT STATUS Social Security Number_______________________ I, _____________________________________________________________________________________________ (PLEASE PRINT FULL NAME) residing at ______________________________________________________________________________________ an employee of (Name of Employer) _________________________________________________________________ at (Place of Employment)__________________________________________________________________________ do hereby certify that I am now receiving, or am entitled to receive, primary old-age insurance benefits under Title Two of the 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 Benefits Law pursuant to Section 235 of the Disability Benefits Law 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 by________________________________________________ State of New York County of _____________________ } ss: On this____________________ day of ________________________ 20_______, before me personally came ______________________________________________________________________________________________ to me known and known to me to be the person described in and who executed the foregoing instrument, and duly acknowledged to me that __________ executed the same. __________________________________ Notary Public The New York State Disability Benefits Law, Section 235, provides: Exemptions. Any employee who is receiving or is entitled to receive old-age insurance benefits under title two of the social security act, shall be exempt from this article upon filing with the chairman and his/her employer a statement, in such form as the chairman shall prescribe, waiving any and all benefits under this article. Thereafter such employee shall be exempt from any liability to contribute toward the cost of such benefits, and his/her employer shall be relieved of responsibility to provide for the payment of any benefits to such employee under this article. THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. DB-130 (5-02) Prescribed by Chairman Workers' Compensation Board State of New York 2002 © American LegalNet, Inc. INSTRUCTIONS 1. Two copies of this form must be completed and signed in the presence of a notary public. 2. Mail one notarized copy to: Workers' Compensation Board Disability Benefits Bureau 100 Broadway-Menands Albany, NY 12241-0005 3. File one notarized copy with your employer. Important -- In order to maintain an exempt status if you change employment, an Employee's Statement of Exempt Status, Form DB-130, must be executed and filed with each new employer and with the Chairman of the Workers' Compensation Board. DB-130 (5-02) Reverse 2002 © American LegalNet, Inc.
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