DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill Districts) PO Box 5205 Binghamton, NY 13902-5205 100 Broadway State Office Building Menands 44 Hawley Street ALBANY 12241 BINGHAMTON 13901 NYC (800)877-1373 / Hemp. (866)805-3630 / Haup. (866)681-5354 / Peek. (866)746-0552 (866) 750-5157 (866) 802-3604 295 Main Street 935 James St. 130 Main Street W. Suite 400 BUFFALO 14203 ROCHESTER 14614 SYRACUSE 13203 (866) 211-0645 (866) 802-3730 (866) 211-0644 State of New York WORKERS' COMPENSATION BOARD APPLICATION FOR AN ADVANCE ON PERIODIC PAYMENTS OF COMPENSATION INSTRUCTIONS: Pursuant to WCL Section 25(5)(b), the Board, upon the application of a claimant, may commute periodic continuing payments made under the WCL into one or more lump sum payments where such commutation would be in the interest of justice. In order for the Board to fully evaluate your application and render a decision thereon, it needs to have information on the circumstances regarding your request. Please answer the questions below carefully and fully. Please remember that any lump sum payment advanced to you will cause an adjustment to future periodic payments made to you by the insurance carrier or self-insured employer. Your application will only be considered once your claim has been finalized with the direction for continuing payments to you. Send your completed application to the district office where your claim was filed. A Board Social Worker will contact you to go over the application. Do not incur any financial obligation on the basis of this application, pending its determination. When a decision is made, you will receive written notice of the decision. W.C.B. CASE NO. CARRIER CASE NO. SOCIAL SECURITY NO. DATE OF ACCIDENT/INJURY ADDRESS NAME APT. NO. INJURED PERSON *EMPLOYER CARRIER APPLICANT'S NAME FOR USE IN DEATH CASES ONLY APPLICANT'S ADDRESS RELATIONSHIP TO DECEASED * In Volunteer Firefighters' and Volunteer Ambulance Workers' Benefits cases, the liable political subdivision is deemed to be the "EMPLOYER". The undersigned hereby makes application for an advance payment from my future compensation payments in the amount of $_________________, and in support of this request submits the following information for the consideration of the Board: 1. Your date of birth: _________________________________ 2. Marital status:________________________________ 3. Number and birth dates of persons dependent on you for support: ___________________________________________ _________________________________________________________________________________________________ 4. List ALL your sources of income and amounts, other than Workers' Compensation benefits:_______________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 5. List your monthly household expenses:__________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ C-21 (1-11) CONTINUED ON REVERSE www.wcb.state.ny.us American LegalNet, Inc. www.FormsWorkFlow.com 6. How will you manage household expenses if your payments are suspended or reduced: _________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 7. Is there currently a child support lien on your Workers' Compensation Benefits ordered by Family Court? __ Yes __ No If Yes, has the Support Collection Unit in your county been notified of this application? __ Yes __ No (Attach written agreement from the Support Collection Unit of your county to the terms of this application.) 8. Are you subject to any other court ordered payments or liens? __ Yes __ No If Yes, explain: _________________________________________________________________________________________________ _________________________________________________________________________________________________ 9. Reason for Request: (State fully what the money is to be used for.)______________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Signature of Applicant Date Telephone No. Notification Pursuant to the New York Personal Privacy Protection Law (Public Officers Law Article 6-A) and the Federal Privacy Act of 1974 (5 U.S.C. Sec. 552a). The Workers' Compensation Board's ("Board") authority to request personal information from claimants is derived from Sections 20 and 142 of the Workers' Compensation Law. This information is collected to assist the Board in processing claims in an efficient manner and to help it maintain accurate claim records. The Board is strongly committed to protecting the confidentiality of all personal information that it collects. Such information will be disclosed within the agency only to Board personnel and agents in furtherance of their official duties. Personal information will be disclosed outside the agency only in accordance with applicablestate and federal law. The Board's Director of Operations, located at 100 Broadway, Menands,New York 12241 (518-474-6674),is primarily responsible for the maintenance of agency records containing personal claimant information. Failure to provide the information requested on this form will not result in the denial of your claim, but may delay the processing of your claim. The voluntaryrelease of your social security number enables the Board to ensure that information is associated with, and quick action is taken on, your claim. C-21 Reverse (1-11) Statewide Fax Line: 877-533-0337 American LegalNet, Inc. www.FormsWorkFlow.com