NEW YORK STATE PUBLIC EMPLOYMENT RELATIONS BOARD PO BOX 2074, ESP AGENCY BLDG 2, FLS 18 & 20, ALBANY, NEW YORK 12220-0074 DECLARATION OF IMPASSE INSTRUCTIONS: Complete in full, retain one copy and distribute in the following manner: A) File an original and one (1) copy with the Director of Conciliation, PERB, PO BOX 2074, ESP AGENCY BLDG 2, FLS 18 & 20, ALBANY, NEW YORK 12220-0074. B) Simultaneously serve one (1) copy upon the respondent. Date: PUBLIC EMPLOYER Name of Public Employer.................................. NAME, TITLE, ADDRESS, EMAIL, TELEPHONE AND FAX NUMBERS of the Representative to whom PERB should direct correspondence (Email) (Telephone) (Fax) EMPLOYEE ORGANIZATION / / - Name of Employee Organization........................ NAME, TITLE, ADDRESS, EMAIL,TELEPHONE AND FAX NUMBERS of the Representative to whom PERB should direct correspondence (Email) (Telephone) (Fax) IDENTIFYING PARTY DECLARING IMPASSE Public Employer _____ Employee Organization _____ / / - Joint Declaration _____ DESCRIPTION OF UNIT A B C D Number of employees in the unit: Included titles: Excluded titles: Employer's fiscal year: (Mo./Day/Yr.) to (Mo./Day/Yr.) (Mo./Day/Yr.) to (Mo./Day/Yr.) IMPORTANT E - Effective date and expiration date of present agreement: F - Date of recognition or certification of negotiating agent: IMPORTANT ON A SEPARATE SHEET OF PAPER DETAILS OF DECLARATION which should be attached hereto, write a clear and concise history of negotiations leading to this Declaration of Impasse. Include the number and dates of the negotiating sessions and specifically list all presently unresolved issues. Pursuant to Article 14 of the Civil Service Law, as amended (Public Employees' Fair Employment Act), the undersigned hereby declare(s) that a state of impasse exists between the above noted public employer and employee organization within the meaning of Section 209 of said Act. Signature of Representative Declaring Impasse Title Date If joint declaration, both representatives must sign: Signature of Representative Declaring Impasse Title Date American LegalNet, Inc. www.FormsWorkFlow.com