Fill and Sign the Nyc800877 1373 Hemp516560 7700 Haup631952 6000 Peek914788 5775 Form

State of New York WORKERS' COMPENSATION BOARD APPLICATION FOR AN ADVANCE ON PERIODIC PAYMENTS OF COMPENSATION INSTRUCTIONS: Pursuant to WCL Section 25(5)(b), the Board, upon the application of a claimant, may commute periodic continuing payments made under the WCL into one or more lump sum payments where such commutation would be in the interest of justice. In order for the Board to fully evaluate your application and render a decision thereon, it needs to have information on the circumstances regarding your request. Please answer the questions below carefully and fully. Please remember that any lump sum payment advanced to you will cause an adjustment to future periodic payments made to you by the insurance carrier or self-insured employer. Your application will only be considered once your claim has been finalized with the direction for continuing payments to you. Send your completed application to the district office where your claim was filed. A Board Social Worker will contact you to go over the application. Do not incur any financial obligation on the basis of this application, pending its determination. When a decision is made, you will receive written notice of the decision. CARRIER CASE NO DATE OF ACCID ENT/INJURY SOCIAL SECURITY NO W C B CASE NO NAME ADDRESS APT NO INJUREDPERSON *EMPLOYER CARRIER RELATIONSHIP APPLICANT'S ADDRESS APPLICANT'S NAME TO DECEASED FOR USE INDEATH CASES ONLY * In Volunteer Firefighters' and Volunteer Ambulance Workers' Benefits cases, the liable political subdivision is deemed to be the ''EMPLOYER'', The undersigned hereby makes application for an advance payment from my future compensation payments in the amount of $ , and in support of this request submits the following information for the consideration of the Board: 1. Your date of birth: 2. Marital status: 3. Number and birth dates of persons dependent on you for support: 4. List ALL your sources of income and amounts, other than Workers' Compensation benefits: 5. List your monthly household expenses: C-21 (2-04) CONTINUED ON REVERSE www.wcb.state.ny.us 130 Main Street W 935 James Street ROCHESTER 14614 SYRACUSE 13203 (866) 211-0644(866) 802-3730 100 Broadway State Office Building Statler Towers DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill Districts) PO Box 5205 Binghamton, NY 13902-5205 NYC(800)877-1373 HEMP(516)560-7700 HAUP(631)952-6000 PEEK(914)788-5775 Menands 44 Hawley Street 107 Delaware Ave. ALBANY 12241 BINGHAMTON 13901 BUFFALO 14202 (866) 750-5157 (866) 211-0645 (866) 802-3604 / / - - 6. How will you manage household expenses if your payments are suspended or reduced:Yes No 7. Is there currently a child support lien on your Workers' Compensation Benefits ordered by Family Court? If Yes, has the Support Collection Unit in your county been notified of this application?Yes No (Attach written agreement from the Support Collection Unit of your county to the terms of this application.) Yes No If Yes, explain: 8. Are you subject to any other court ordered payments or liens? 9. Reason for Request: (State fully what the money is to be used for.) Date Signature of Applicant Telephone No. Notification Pursuant to the New York Personal Privacy Protection Law (Public Officers Law Article 6-A) and the Federal Privacy Act of 1974 (5 U.S.C. Sec. 552a). The Workers' Compensation Board's (''Board'') authority to request personal information from claimants is derived from Sections 20 and 142 of the Workers' Compensation Law. This information is collected to assist the Board in processing claims in an efficient manner and to help it maintain accurate claim records. The Board is strongly committed to protecting the confidentiality of all personal information that it collects. Such information will be disclosed within the agency only to Board personnel and agents in furtherance of their official duties. Personal information will be disclosed outside the agency only in accordance with applicable state and federal law. The Board's Director of Operations, located at 1 00 Broadway, Menands, New York 12241 (518474-6674), is primarily responsible for the maintenance of agency records containing personal claimant information. Failure to provide the information requested on this form will not result in the denial of your claim, but may delay the processing of your claim. The voluntary release of your social security number enables the Board to ensure that information is associated with, and quick action is taken on, your claim. C-21 Reverse (2-04)