WTC-12 (9-1) !#"$NYS Workers325 Compensation Board Centralized Mailing Address: P.O. Box 5205, Binghamton, N.Y. 13902!!!!!!!!!!!!!www.wcb.ny.gov State of New York WORKERS' COMPENSATION BOARD REGISTRATION OF PARTICIPATION IN WORLD TRADE CENTER RESCUE, RECOVERY AND/OR CLEAN-UP OPERATIONS (Sworn Statement Pursuant to Workers' Compensation Law 244162) Please read the background and instructions below completely and carefully beforeBACKGROUND On August 14, 2006, Workers' Compensation Law (WCL) Article 8-A was enacted to expand the time for a"participant" in World Trade Center rescue, recovery and/or clean-up operations who suffers, or may suffer in thefuture, from a "qualifying condition" to file a claim for workers' compensation lost wage and medical benefits andto permit the Board to reopen such claims previously denied as untimely. Article 8-A was recently amendedtoINSTRUCTIONS A.If you were a "participant" in World Trade Center rescue, recovery, and/or cleanup operations, as that term isdefined above, you are required American LegalNet, Inc. www.FormsWorkFlow.com WTC-12 (9-1) !%"$NYS Workers325 Compensation Board Centralized Mailing Address: P.O. Box 5205, Binghamton, N.Y. 13902!!!!!!!!!!!!!www.wcb.ny.gov Please complete the Sworn Statement by providing the following information:Item 1 - Give your current residential address, including apartment number (if applicable), street number, street name,city, state and zip code. Give mailing address if different from the residential address provided. Be sure to includeyour telephone number. Please provide your Social Security Number and your date of birth by month/date/year.2 - This sentence just states that you participated in the World Trade Center rescue, recovery and cleanupoperations between September 11, 2001, and September 12, 2002, at the World Trade Center site, the Fresh KillsLand Fill, the New York City morgue or temporary morgue, or the barges between the west side of Manhattan andthe Fresh Kills Land Fill.Item 3 - State whether you participated in the World Trade Center rescue, recovery and/or clean-up operationsas an employee (in the course of your employment for pay) or as a volunteer (not in the course of your employment,but upon your own initiative without pay);Item 4 - List with a brief description any evidence of your activities as a volunteer, for example, badge, letters,statements, pictures, accommodations, etc.;Item 5 - Fill in the table. Specify the dates and locations of your participation in World Trade Center rescue,recovery and/or cleanup operations to the best of your ability. Describe the work you performed at each location onthe date or dates you were there. Give the complete name and address of your employer (s)or the rescueentity/volunteer agency you volunteered with during the period of participation in World Trade Center rescue,recovery and/or clean-up operations, and if applicable and you know, the name of your employer's insurancecarrier; andItem 6 - Indicate whether you previously filed a workers' compensation claim with the Board relating to yourparticipation in World Trade Center rescue, recovery and/or cleanup operations. If you have, you must includethe date the claim was filed and the WCB case number.Item 7 - This item states your understanding that filing the Sworn Statement, and thereby registering as a"participant," is not the same as filing a claim for workers' compensation benefits. To file a claim for benefits youmust timely submit to the Board Form C-3 or Form WTCVol-3.Item 8 - This item states that you understand that the law penalizes those who submit false written documentsto the Board and for making false statements.After you complete the Sworn Statement, please review it to insure that it is truthful and accurate.Sign the Sworn Statement in front of a notary public. Your signature on the Sworn Statement must be notarized orthe comparable process for the jurisdiction in which you are located when signing this Statement. Do not sign theSworn Statement until you are in the presence of the notary public. PLEASE NOTE: by signing this statement,you swear and affirm that the information provided and statements made therein are true under the penalty ofperjury. You are also stating that you understand that the law prescribes penalties for perjury, for willfully makingfalse statements in connection with an insurance claim, and for submitting a false instrument for filing.You must file the original Sworn Statement with the Board not later than September 11, 20 to the Board325sCentralized Mailing Address: P.O. Box 5205, Binghamton, N.Y. 13902. ADDITIONAL INFORMATION Filing this Sworn Statement with the Board is NOT considered the filing of a claim for workers' compensationbenefits. In order to file a claim for workers' compensation benefits, you must submit a Form C-3 (Employee'sClaim for Compensation) or WTCVol-3 (World Trade Center Volunteer's Claim for Compensation) to the Board inatimely manner.PLEASE NOTE: If you previously filed a claim for workers' compensation benefits relating to your participation inWorld Trade Center rescue, recovery and/or cleanup operations, which was disallowed by the Board because you didnot give timely notice to your employer or did not file a claim with the Board within the time allowed, the Boardwill reopen and reconsider such claim PROVIDED your Sworn Statement is filed with the Board not later thanSeptember 11, 20.PLEASE NOTE:!"participant" must register by filing a Sworn Statement with the Board not later than September 11, 20, inorder for the extended claim filing period to apply to his/her claim.!If a "participant" has already filed a claim for workers' compensation benefits for a "qualifying condition" which wasdisallowed as untimely and now fails to timely file a Sworn Statement with the Board, the "participant's" claim will notbe reopened and reconsidered by the Board. Except that a claim by a participant in the World Trade Center rescue,recovery or cleanup operations whose disablement occurred between September 11, 2012 and September 11, 201,shall not be disallowed as barred by Section 18 or Section 28 of this chapter if such claim is filed on or beforeSeptember 11, 20. Any such claim by a participant in the World Trade Center rescue, recovery or cleanup operationswhose disablement occurred between September 11, 2012 and September 11, 201, and was disallowed by Section 18or 28 of this chapter shall be reconsidered by the Board.!The extended period in which to file a claim will only apply to the claim of a "participant" who registers byfiling a Sworn Statement with the Board not later than September 11, 20. American LegalNet, Inc. www.FormsWorkFlow.com WTC-12 () -3 -NYS Workers222 Compensation Board Centralized Mailing Address: P.O. Box 5205, Binghamton, N.Y. 13902 www.wcb.ny.gov Registration of Participation in World Trade Center Rescue, Recovery and/or Clean-up Operations (Sworn Statement Pursuant to Workers' Compensation Law 247162) REGISTRATION IS NOT THE FILING OF A CLAIM FOR WORKERS' COMPENSATION BENEFITS In the Matter of the Registration of , Participant (Your first name, middle initial and last name) SWORN STATEMENT Regarding Participation in World Trade Center Rescue, Recovery and/or Clean-up Operations. WCL247162 ******************************* State of ) (State/province where you have this notarized) ) ss County of (County, or country if outside U.S.A., where you have this notarized) I, (print first name, middle initial and last name) being duly sworn, depose and say: 1.I am the above named Participant, and I reside at (provide street number and name, city, state, zip codeand country if not U.S.A.). My mailing address (if different from residential address is.My telephone number is (area code, number). My Social Security Number is (optional) and my date of birth is . 2.I was a participant in World Trade Center rescue, recovery, and/or clean-up operations as that term isdefined in Workers' Compensation Law 247161 (1). (See instruction page for complete definition.) 3.I participated in the World Trade Center rescue, recovery and/or clean-up operations as defined inWorkers' Compensation Law 247161 (1) a