Scsep Third Party Attestation Forms - U.s. Department Of Labor Page 12
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12Third-Party Attestation Form for Item U28c/U29c/U29e/U30c
Any wages for first/second/third/fourth quarter after exit quarter?
On this date, I attest that __________________________________________ (Name of Participant) received wages from
___ / ___ / ______ to ___ / ___ / ______, which is after he/she exited from the SCSEP program.
-------------------------------------------------------
OR
-------------------------------------------------------
On this date, I attest that __________________________________________ (Name of Participant)
_____ is deceased.
_____ is unable to continue participating in the SCSEP program and unable to work based on one of the following
statements:
_____ He/She has a documented health/medical exclusion, that is:
1. he/she is in the care of Dr. ____________________ (Name of Doctor), and
2. I have has been informed by Dr. ____________________ (Name of Doctor)that
a. his/her medical condition is expected to last at least 90 days, and
b. his/her medical condition prevents him/her from continued participation in the SCSEP
program and from working.
_____ He/She has a documented family care exclusion, that is:
1. he/she is providing care for _____________________________ (Name of Relative and
Relationship to Participant), who is a member of his/her family, and
2. the family member is in the care of Dr. ____________________________ (Name of Doctor), and
3. I have been informed by Dr. ____________________________ (Name of Doctor) that the
medical condition is expected to last at least 90 days, and
4. the family member requires a level of care which prevents me from continued participation in the
SCSEP program or from working.
_____ He/She is institutionalized, that is:
1. he/she is receiving 24-hour care at _________________________ (Name of Facility), which is a
facility such as a prison or a hospital, and
2. I have been informed by _____________________________ (Name and Position) that he/she is
expected to remain at this facility for at least 90 days, which prevents him/her from continued
participation in the SCSEP program and from working.
Specific information about your relationship to the applicant and an explanation of how you are in a knowledgeable
position to attest to the facts cited above is required. Please provide this information below (Note: Use the back of this
form if additional space is needed):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_____________________________________
_____________________________________
(Name of Attesting Individual)
(Relationship of Attesting Individual to Participant)
_____________________________________
___________________
(Signature of Attesting Individual)
(Date)
SCSEP Third Party Attestation Forms
page 12 of 12
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