Scsep Third Party Attestation Forms - U.s. Department Of Labor Page 4
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12Third-Party Attestation Form for Item P13
Employed prior to participation?
On this date, I attest that __________________________________________
(Name of Applicant)
is not employed at the time of application, that is:
1. he/she does not do any work at all as a paid employee; and
2. he/she does not do any work at all in his/her own business, profession, or farm; and
3. he/she does not work 15 hours or more as an unpaid worker in an enterprise operated by a
member of his/her family; and
4. he/she does not have a job or business from which he/she was temporarily absent because
of illness, bad weather, vacation, labor-management dispute, or personal reasons.
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 Applicant)
_____________________________________
_______________________
(Signature of Attesting Individual)
(Date)
SCSEP Third Party Attestation Forms
page 4 of 12
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