Pennsylvania > Workers Comp
Executive Officers Declaration LIBC-513 - Pennsylvania
| Executive Officers Declaration Form. This is a Pennsylvania form and can be used in Workers Comp . |
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Commonwealth of Pennsylvania Department of Labor and Industry Bureau of Workers' Compensation COMPLIANCE SECTION 1171 S. Cameron Street Room 103 Harrisburg, PA 17164-2501 (717)787-3567 EXECUTIVE OFFICER'S DECLARATION INSTRUCTIONS: Each executive officer having an ownership interest in a corporation seeking exemption must complete an original Declaration for submission with the Corporation's Application for Executive Officer Exception. The total ownership interest of all Declarations combined must equal 100%. See the Form Completion Hints on the reverse side for additional information and the Application for Executive Officer Exception for filing instructions. I, the below named Executive Officer, do hereby knowingly and voluntarily elect not to bean employee of the below named corporation for purposes of the Pennsylvania Workers' Compensation Act, and waive any and all benefits and rights to which I might be entitled under the Pennsylvania Workers' Compensation Act (77 P.S. §1, et seq). I do hereby state and affirm that I am an executive officer who: (check only one box) Has an ownership interest in a Subchapter S corporation as defined by the Federal Tax Reform Code of 1971. Has at least 5% ownership interest in a Subchapter C corporation as defined by the Federal Tax Reform Code of 1971. Serves voluntarily and without remuneration in a nonprofit corporation. I, the undersigned, verify that the facts set forth in this Executive Officer's Declaration are true and correct to the best of my knowledge, information and belief. This verification is made subject to the penalties of 18 PA. C.S. § 4904, relating to unsworn falsification to authorities. Month Day Year Signature of Executive Officer Date Corporations Full Legal Name Title of Executive Officer First Name Middle Name Last Name Suffix (ex: Jr.) Social Security Number Percentage of Ownership Telephone Address (Business or residence address acceptable City State Zip LIBC-513 REV 10-01 For Bureau Use ONLY. ..... American LegalNet, Inc. www.USCourtForms.com FORM COMPLETION HINTS In General: This form will be machine-read by the Bureau of Workers' Compensation. The red lines and boxes will ''drop out'' during processing so that the information typed or written (typed is preferable) on the form can be automatically ''read'' and used by the Bureau's computer system. Forms that do not meet Bureau requirements will be rejected. Do not staple forms together. Where to Type: When typing a form, begin in the left most box of each set of red boxes. Use normal spacing (do not put one letter per box) staying within the range of boxes. Avoid typing in the margins. Use black ink only. For example: First Name Last Name JOHNATHAN JONES Where to Handwrite: When completing a form by hand, print clearly, using uppercase letters, in black ink only, placing one letter or numeral within each box. For example: First Name Last Name JOHNATHAN Dates: Enter all dates as MMDDYYYY. For example: Month Day Year JONES Month Day Year 04271999 - - OR 04 - 27 - 1999 Telephone Numbers: The first three digits are the area code. No need for parenthesis. For example: Telephone Telephone 7175553894 - OR 717 -555 - 3894 American LegalNet, Inc. www.USCourtForms.com
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