The completed typewritten form must be filled out correctly prior to emailing your request. Incorrectly filled forms will be rejected.Formally conclude agreements with our termination of agreement and release template. Prevent future disputes and ensure clarity for all parties involved. A sample of an affidavit of service is attached. This application is to be used to apply for approval of agencies as early intervention evaluators, service providers and service coordinators. Agreement effective as of. , between WORKMEN'S CIRCLE MULTICARE CENTER, located at. 3155. Grace. Avenue,. Bronx,. New. York. 10469. (hereinafter. View and print the small claims claim form. You can watch a short tutorial to explain how to fill in the form.