Form Libc 513 PDF Details

Form libc 513 is an open source C library that helps developers quickly create and deploy secure applications. The library provides a variety of cryptographic functions, including message authentication codes, digital signatures, and key exchange algorithms. It also includes support for elliptic curve cryptography. Form libc 513 is available under the GNU Lesser General Public License.

QuestionAnswer
Form NameForm Libc 513
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameslibc 513, uppercase, 1971, Cameron

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Commonwealth of Pennsylvania

Department of Labor & Industry

Bureau of Workers’ Compensation

COMPLIANCE SECTION

1171 S. Cameron Street, Room 103

Harrisburg PA 17104-2501

(717)787-3567

EXECUTIVE OFFICER’S DECLARATION

INSTRUCTIONS: Each executive officer having an ownership interest in a corporation seeking exemption must complete an original Declaration for submission with the Corporation’s Application for Executive Officer Exception. The total ownership interest of all Declarations combined must equal 100%. See the Form Completion Hints on the reverse side for additional information and the Application for Executive Officer Exception for filing instructions.

I, the below named Executive Officer, do hereby knowingly and voluntarily elect not to be an employee of the below named corporation for purposes of the Pennsylvania Workers’ Compensation Act, and waive any and all benefits and rights to which I might be entitled under the Pennsylvania Workers Compensation Act (77 P.S. §1, et seq.).

I do hereby state and affirm that I am an executive officer who: (check only one box)

Has an ownership interest in a Subchapter S corporation as defined by the Federal Tax Reform Code of 1971.

Has at least 5% ownership interest in a Subchapter C corporation as defined by the Federal Tax Reform Code of 1971. Serves voluntarily and without remuneration for a nonprofit corporation

I, the undersigned, verify that the facts set forth in this Executive Officer’s Declaration are true and correct to the best of my knowledge, information and belief. This verification is made subject to the penalties of 18 Pa.C.S. § 4904, relating to unsworn falsification to authorities.

Month Day Year

Signature of Executive Officer

 

Date

Corporation’s Full Legal Name

Title of Executive Officer

First Name

-

-

Middle Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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0705

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Suffix (ex: Jr.)

 

Social Security Number

 

 

 

 

 

 

 

Percentage of Ownership

Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address (Business or residence address acceptable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

For Bureau Use ONLY….

LIBC-513 REV 7-05 (Page 1)

FORM COMPLETION HINTS

In General:

This form will be machine-read by the Bureau of Workers Compensation. The red lines and boxes will “drop out” during processing so that the information typed or written (typed is preferable) on the form can be automatically “read” and used by the Bureau’s computer system. Forms that do not meet Bureau requirements will be rejected. Do not staple forms together.

Where to Type:

When typing a form, begin in the left most box of each set of red boxes. Use normal spacing (do not put one letter per box) staying within the range of boxes. Avoid typing in the margins. Use black ink only. For example:

First Name

JOHNATHAN

Last Name

JONES

Where to Handwrite:

When completing a form by hand, print clearly, using uppercase letters, in black ink only, placing one letter or numeral within each box. For example:

First Name

J O HN A T H A N

Dates:

Enter all dates as MMDDYYYY. For example:

Last Name

J ON E S

Month

Day

Year

Month

Day

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

04272005

 

 

 

 

 

 

 

OR

0

4

 

2

7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Numbers:

The first three digits are the area code. No need for parenthesis. For example:

2 0 0 5

Telephone

7175553894

OR

Telephone

7 1 7

5 5 5

3 8 9 4

Auxiliary aids and services are available upon request to individuals with disabilities.

Equal Opportunity Employer/Program

LIBC-513 REV 7-05 (Page 2)

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