Form Oc-401.1 - Initial Application For License To Appear On Behalf Of Claimant (Page 4 of 4) in pdf

Form Oc-401.1 - Initial Application For License To Appear On Behalf Of Claimant Page 4

PRIVACY NOTIFICATION

The authority to request personal information from you, including identifying numbers such as

Federal Social Security and Federal Employer Identification Numbers, and the authority to maintain

such information, is found in Section 5 of the Tax Law. Disclosure of this information by you is

mandatory. The principal purpose for which this information is collected is to enable the Department

of Taxation and Finance to identify individuals, businesses and others who have been delinquent in

filing tax returns or may have understated their tax liabilities and to generally identify persons

affected by the taxes administered by the Commissioner of Taxation and Finance. The information

will be used for tax administration purposes and for any other purpose authorized by the Tax Law or

the Workers' Compensation Law.

The information collected will be held by the Licensing Unit, Workers' Compensation Board. All

inquiries regarding such records should be addressed to the Privacy Compliance Officer, Office of

the General Counsel, Workers' Compensation Board, 328 State Street, Schenectady, NY 12305, or

call (518) 486-9564.

_____________________________________________________________________________

If you have neither a Social Security Number or Federal Employer Identification Number,

please provide an explanation in the space below: (see Question 5 on page 1).

Signature of Applicant

OC-401.1 (9-07) Page 4

Form Oc-401.1 - Initial Application For License To Appear On Behalf Of Claimant Page 4