Form Rb-89.3 - Cover Sheet - Rebuttal Of Application For Reconsideration / Full Board Review Page 2

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Certification: By signing this document in the space provided below, I certify that this rebuttal has a good faith basis in law and fact, has been instituted with

reasonable grounds, and has been served upon all parties at the addresses listed in the affirmation or affidavit of service below. I understand that the

Workers' Compensation Law provides for substantial penalties for instituting or continuing proceedings without reasonable grounds and/or for the purpose of

delay. I understand that if the application for Board review is withdrawn for any reason or if any of the issues raised are resolved by the parties, the Board and

the parties served must be notified immediately in writing.

Signature of Person Preparing Form

Date ______/______/______

Print Name

Title

Phone Number (______)______________

SECTION 1

AFFIRMATION

STATE OF NEW YORK, COUNTY OF ________________ ss: I, the undersigned, am an attorney duly admitted to the practice of law in the courts of the

state of New York. I hereby certify that I have complied with the filing and service requirements for this Rebuttal of an Application for Full Board Review in

the manner described in Section 2 below.

I affirm that the foregoing statements are true under penalties of perjury.

Dated ______________________ Signature _______________________________________________________

Signer's Name (Print) ______________________________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

AFFIDAVIT

STATE OF NEW YORK, COUNTY OF ________________ ss: I, _______________________________________________________, being duly sworn,

say: I am over 18 years of age. I hereby certify that I have complied with the filing and service requirements for this Rebuttal of an Application for Board

Review in the manner described in Section 2 below.

Sworn to before me on _________________

Signature ___________________________________________________________

____________________________________

Signer's Name (Print) _________________________________________________

Notary Public

SECTION 2

A. Method by which Rebuttal was Filed with the Board (Check One):

Fax (1-877-533-0337)

E-Mail (wcbclaimsfiling@wcb.ny.gov)

Mail (specify date below)

Personal Delivery (specify date below)