Eclaration for submission with the Corporation s Application for Executive Officer Exception. The total ownership interest of all declarations combined must equal 100 percent. 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 which I might be entitled under the Pennsylvania Workers Compensation Act (77 P.S.
Loading
Open form follow the instructions
Easily sign the form with your finger
Send filled & signed form or save
How to fill out the PA LIBC-513 online
The PA LIBC-513 form is an essential document for executive officers seeking exemption under the Pennsylvania Workers’ Compensation Act. This guide provides a user-friendly approach to help you complete this form accurately and efficiently.
Follow the steps to successfully fill out the PA LIBC-513 online.
- Click ‘Get Form’ button to access the PA LIBC-513 form and open it in the online editor.
- Begin by entering your full name in the appropriate fields—first name, middle name, last name, and suffix, if applicable.
- Provide your date of birth by entering the month, day, and year in the specified format.
- Enter your Social Security number in the designated field to ensure proper identification.
- Indicate your title as an executive officer of the corporation in the corresponding field.
- Fill in the corporation's full legal name to clarify the entity for which you are seeking exemption.
- Select only one option to indicate your ownership interest in the corporation by checking the appropriate box.
- Input the percentage of your ownership interest in the specified area, ensuring it is accurate and totals 100 percent with other declarations.
- Provide your contact telephone number in the format requested to ensure that you can be reached if needed.
- Complete the address section with either your business or residence address, including city, state, and ZIP code.
- Review all provided information for accuracy before signing the document in the designated area.
- Once you have filled out the form, ensure to save your changes, and you may then download, print, or share the form as necessary.
Take action now and complete your PA LIBC-513 form online.
Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Related content
This verification is made subject to the penalties of 18 Pa.C.S. §4904, relating to...
Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
If you believe that this page should be taken down, please follow our DMCA take down process here.