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Get Lc 5012 2010-2024

AND SUBJECT TO FINES AND IMPRISONMENT. Electronic Funds Transfer (EFT) is our standard method of payment. When making our claim decision we may contact you to obtain your banking information. Claim signed on: Claimant's Signature: If signed by other than claimant, print below: name, address, and relationship of representative: IF YOU HAVE ANY QUESTIONS ABOUT CLAIMING DISABILITY BENEFITS, SI TIENE DUDAS RELACIONADAS CON LA RECLAMACIÓN DE BENEFICIOS CONTACT THE NEAREST OFFICE OF THE NYS WORKERS.

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