State of Florida, Division of Administrative Hearings Office of the Judges of Compensation Claims 1203 Governors Square Boulevard, 6th Floor, Tallahassee Florida 32301 (850) 487-1911 VERIFIED M OTI ON FOR ASSIGNMENT OF SUBSTI TUTE IDENTIFI CATION NUMBER INSTRUCTIONS: Fill this form in completely, sign it in the presence of a commissioned notary, show identification to the notary, and submit this completed form along with your Petition for Benefits or Request for Assignment of Case Number. 1. My name is_______________________________ 2. My date of birth is _____________ __ 3. My residence address is _____________________________________________ ___________ 4. I do not have, or I decline to provide, a Social Security Number. WHEREFORE, the employee requests that the Office of the Judges of Compensation Claims obtain and assign a substitute identification number from the Division of Workers Compensation. By signing below, I swear or affirm, under penalties of perjury, that the facts stated on this document are true and accurate. Employees Signature _____________________________________ Country of _________________, State of _________________, County of ____ _____________ The foregoing document was acknowledged before me this ____day of ____________, 20____, by ________________________________, who is personally known to me or who has produced identification and who took an oath/affirmed. The Identification Presented to the Notary Public is ___________________________________ Signature of Notary Public _________________________ (Notary Public Seal) Name of Notary Public ____________________________ My commission expires _________________ This section must be completed by the notary if documentary identification is unavailable. Statement of Reason for Unavailability of Documentary Identification: ____________________ ________________________________________________________________________ _____ Basis of Personal Knowledge of the Affiant: _________________________________________ ________________________________________________________________________ _____ Verified Motion for Assignment of Substitute Identification Number American LegalNet, Inc. www.USCourtForms.com