Form Ds-1 - Claim For Disability Benefits - New Jersey Department Of Labor And Workforce Development Page 4

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WDS-1 (R-1-07)
Claimant’s Name:_________________________________________
Social Security Number
|
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Claimant’s Telephone No: (_____)___________________________
CLAIMANT’S AUTHORIZATION AND CERTIFICATION STATEMENTS
PART A1
MUST BE COMPLETED AND SIGNED BY THE CLAIMANT
1. Please designate a representative to obtain claim information for you if you cannot call this Agency yourself. The Law only permits
claim information to be given to you or your representative.
Representative Name: ___________________________________________________Birth Date:_____________________________
Phone (______ )____________________________________
2. Certification and Signature I was unable to work during the period for which benefits are claimed and hereby certify that I have
read and understand my benefit rights and responsibilities. I am aware that if any of the foregoing statements made by me are known to
be false, or I knowingly fail to disclose a material fact, I may be subject to penalties, which may include criminal prosecution. You are
hereby authorized to verify my Social Security Account Number, and obtain any medical, employment and Social Security benefit
entitlement information that is necessary to determine my eligibility for benefits.
Sign Here ________________________________________________________________Date______________________________
Witness signature if claimant writes an “X” _______________________________________________________________________
Phone No. (_____)_____________________________ E-Mail Address _______________________________________________
Note: The NJ Temporary Disability Benefits Program is not a “covered entity” under the Federal Health Information Portability &
Accountability Act (HIPAA). All medical records of the Division, except to the extent necessary for the proper administration of the
Temporary Disability Benefits Law are confidential & are not open to public inspection. The Division protects all records that may
reveal the identity of the claimant, or the nature or cause of the disability and the records may only be used in proceedings arising under
the Law.
USE THIS SPACE TO LIST ADDITIONAL EMPLOYERS FOR QUESTION 19.
Name and address:
Period of employment: From _______________ To____________
month/day/year
month/day/year
__________________________________________________
Work
Telephone: ______________ Location ______________________
__________________________________________________
City
State
(Street)
(City)
(State)
(Zip)
Occupation: ________________________________ Full time
Part time
Union _____________Division___________________
Check the days of the week you normally work. SUN
MON
TUE
WED
THUR
FRI
SAT
Name and address:
Period of employment: From _______________ To____________
__________________________________________________
month/day/year
month/day/year
Work
Telephone: ______________ Location ______________________
__________________________________________________
City
State
(Street)
(City)
(State)
(Zip)
Occupation: ________________________________ Full time
Part time
Union _____________Division___________________
Check the days of the week you normally work. SUN
MON
TUE
WED
THUR
FRI
SAT
USE THIS SPACE TO PROVIDE ANY ADDITIONAL INFORMATION FOR QUESTIONS ON PART A
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
If more space is needed, attach an additional sheet of paper. Be sure your Social Security Number appears on all pages.

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