Form Libc 14B – Fill Out and Use This PDF

Form Libc 14B is a widely respected survey used by organizations around the world. It assesses the participants' attitude, behavioral intentions, and values towards various products, services, experiences, and activities. The survey implements leading edge sampling techniques and processes to capture true responses that are precise, on target and reflective of today's marketplace needs. More specifically, the platform attempts to build an understanding of the following components: Ad Control Dynamics, Market Strength Dynamics, Portfolio Dynamics, Innovation Effect Dynamics and Shopper Loop Dynamics. With thorough feedback from this comprehensive questionnaire perspectives are developed to inform research into decision making processes and encourage clarity within difficult market situations. A striving priority of FormLibc14B is to provide insightful lines within a broad spectrum of research looking to reach customers on a highly efficient positioning mindset for maximum success within any industry standards.

Form Libc 14B PDF Details

Form Libc 14B is a library form that should be used when filing a library copyright application. The form can be found on the US Copyright Office website and must be completed and submitted along with other required materials in order to receive a copyright registration for your library. using Form Libc 14B helps ensure that your library's copyrights are protected and easy to track. Completing this form correctly is important, so make sure to consult the US Copyright Office website or an attorney if you have any questions.

Question	Answer
Form Name	Form Libc 14B
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	waiving, CAMERON, HARRISBURG, EMPLOYE

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LIBC-14B REV 7-02

COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS’ COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501

EMPLOYE’S AFFIDAVIT AND WAIVER OF WORKER’S COMPENSATION BENEFITS AND STATEMENT OF RELIGIOUS SECT

(To be filed with the §304.2Application

forReligiousException)

	EMPLOYE			EMPLOYER

	STREET ADDRESS
	STREET ADDRESS			STREET ADDRESS
				STREET ADDRESS

CITY/TOWN	STATE	ZIP CODE
CITY/TOWN	STATE	ZIP CODE	CITY/TOWN	STATE	ZIP CODE
			CITY/TOWN	STATE	ZIP CODE

EMPLOYE SOCIAL SECURITY NUMBER

WAIVER OFWORKERS’COMPENSATIONANDAFFIDAVIT

I, _______________________________ , do hereby state and affirm that I am a member of ______________

EMPLOYE

____________________________________. Its established tenets and/or teachings conscientiously oppose

RELIGIOUS SECT OR DIVISION

member acceptance of any public or private insurance benefits which make payments in the event of death, disability, old age, retirement, or towards the cost of medical bills and provision of services for medical bills (includingthebenefitsofanyinsurancesystemestablishedbytheFederalSocialSecurityAct),andIadheretosaid tenets and/or teachings. I am, therefore, knowingly and voluntarily waiving my rights to any benefits under the PennsylvaniaWorkers’CompensationAct.

Subscribed and affirmed to before me this

_______ day of __________________ , 20 ____

		SIGNATURE OF EMPLOYE
		(OR PARENT OR GUARDIAN IN CASE OF MINOR

NOTARY PUBLIC	(SEAL)

STATEMENTOFRELIGIOUS SECT

I,____________________________________,hereby state and affirm that I am the religious leader of__________

RELIGIOUS SECT LEADER

________________________________ , and I verify that _____________________________ is a current

RELIGIOUS SECTABOVE-NAMED EMPLOYE

member of this sect. I state and affirm that this religious sect has established tenets and/or teachings which oppose its members’ acceptance of any public or private insurance benefits which make payments in the event of death, disability,oldage,retirement,ortowardthecostofmedicalbillsandprovisionofservicesformedicalbills(includ- ing the benefits of any insurance system established by the Federal Social SecurityAct). Furthermore, I state and affirm that it is the practice, and has been for ________ for members of this sect or division to make provision for

NUMBER OF YEARS

their dependent members which, in its judgment, is reasonable in view of their general level of living.

SIGNATURE OF RELIGIOUS SECT LEADER

TITLE

DATE

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2. After filling out this part, go to the subsequent stage and complete all required particulars in all these fields - STATEMENT OF RELIGIOUS SECT, I hereby state and affirm that I, RELIGIOUS SECT LEADER, and I verify that is a current, RELIGIOUS SECT, ABOVENAMED EMPLOYE, member of this sect I state and, their dependent members which in, NUMBER OF YEARS, SIGNATURE OF RELIGIOUS SECT LEADER, TITLE, and DATE.

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Form Libc 14B – Fill Out and Use This PDF

Form Libc 14B PDF Details

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