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DISABILITY CLAIM FORM
Apply a voluntary state income tax withholding to each benefit payment? Yes. No. If Yes, select one of the following: Withhold $. ($10.00 minimum).
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DB-450 (6/22) - Workers Compensation Board - New York State
If you are using this form because you became disabled after having been unemployed for more than four (4) weeks, your completed claim MUST be mailed to:
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INSTRUCTIONS FOR FILLING OUT FORM FDA 3542a
Use this Form FDA 3542a only if the NDA applicant is submitting information on a patent that claims a proposed drug or a proposed method of using the drug that
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