Cancellation Of Election Of A Noncompensated Volunteer Officer Director Or Trustee Of A Nonprofit Corp
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Cancellation Of Election Of A Noncompensated Volunteer Officer Director Or Trustee Of A Nonprofit Corp Form. This is a Kansas form and can be use in Workers Compensation.
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Tags: Cancellation Of Election Of A Noncompensated Volunteer Officer Director Or Trustee Of A Nonprofit Corp, K-WC-137a, Kansas Workers Compensation,
DIVISION OF WORKERS COMPENSATION
KS DEPARTMENT OF LABOR
800 SW JACKSON ST STE 600
TOPEKA KS 66612-1227
Phone: 785-296-2996 – Fax: 785-296-0025
Web Site: www.dol.ks.gov
Cancellation of Election of a Noncompensated Volunteer Officer,
Director or Trustee of a Nonprofit Corporation to Be Covered
Under Kansas Workers Compensation Act
N
OTICE: To be processed, ALL entries on this form must be completed. All
entries, except signatures, must be neatly printed in black ink.
NOTE: This Cancellation of Election is effective upon receipt by the
Kansas Division of Workers Compensation.
To the Kansas Division of Workers Compensation, you are hereby notified that:
Employee’s Name: _____________________________________________________________________
Employee’s Social Security Number: ______________________________________________________
Nonprofit Corporation Name: ____________________________________________________________
Address of Nonprofit Corporation: _________________________________________________________
_____________________________________________________________________________________
Telephone Number: (_______)_____________________
hereby cancels his/her previous election to come within the provisions of the Kansas Workers
Compensation Act.
_____________________________________________
Signature of Employee (Must be Notarized)
_______________________________
_______________________________
Title/Position
Date Signed
State of ______________________________
County of _____________________________
Signed, acknowledged or attested
)
)
) SS:
)
)
(Seal, if any)
before me on __________________________
by ___________________________________
_____________________________________
(Signature of notarial officer)
My appointment expires: _________________
Federal Privacy Act Disclosure Section 7(a)(2)(B)
The mandatory requirement that social security numbers be included on forms filed with the Division of Workers Compensation is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of 1974, since our regulations which
require its disclosure were in existence before January 1, 1975. The number is used as a means of identifying all
the various records in the Division of Workers Compensation pertaining to an individual.
The use of social security numbers is made necessary because of the large number of applicants who have
similar names and birth dates, and whose identities can only be distinguished by the social security number.
K-WC 137a (Rev. 5-10)
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