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WESTCHESTER COUNTY TAXI & LIMOUSINE COMMISSION

Department of Public Safety • 112 East Post Road • White Plains, New York 10601 • (914) 995-8400

AFFIDAVIT

NOTE TO THE MEDICAL PROVIDER APPLICANT

YOU MUST SUBMIT AFFIDAVITS FROM ALL HEALTH AND / OR SOCIAL SERVICE ORGANIZATIONS YOU DO BUSINESS WITH.

YOU MAY MAKE PHOTOCOPIES OF THIS FORM AS NECESSARY. THIS FORM MUST BE SIGNED AND NOTARIZED.

____________________________________

has filed an application for a medical provider waiver with the Westchester

(Name of vehicle owner applying for Medical Waiver)

County Taxi & Limousine Commission (WCTLC). The applicant has stated that your organization uses his/her vehicle(s) for transportation

services. Please complete this form and return it to the applicant as soon as possible.

1. Do you currently use the applicant’s vehicle(s) for medical transportation?

[ ] Yes [ ] No

2. Does your organization uses the applicant’s for any purpose other than medical

[ ] Yes [ ] No

transportation? If yes, provide details. ______________________________________________________________

________________________________________________________________________________________________

3. How long has your organization been doing business with the applicant?

___ Yrs ___ Mos

4. Does the applicant charge your company state sales tax for its services?

[ ] Yes [ ] No

5. How often does your company use the applicant’s vehicle(s)? _____________________________________________

Read the following and sign below.

The information listed above is complete and accurate to the best of my knowledge. I understand that, pursuant to §210.45 of the

NYS Penal Law, it is a crime punishable as a Class “A” misdemeanor to knowingly make a false statement herein.

I, being duly sworn, state the following: I am the authorized personnel of the organization listed below and I am authorized

to sign on behalf of the organization listed below.

Print Name of Organization: ___________________________________________________ Phone # (_____) _____-___________.

Print Name of Authorized Personnel of the Organization: _______________________________ Title:______________________

Dated: ___________________________ Signature: ________________________________________________________________

(Authorized Organization Personnel)

State of New York

Sworn to before me this ___________day of ________________, 2_____,

County of ((______________)) ss:

_____________________________________________________________

Notary Public Signature

WCPD322 (Rev 09/2016)

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Form Wcpd322 - Medical Provider Waiver Application - Westchester County Taxi & Limousine Commission Page 3