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Substituteform rev 01 05 2026

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  2. Begin by entering your Full Name in the designated field, ensuring you include your last name, followed by your first and middle names.
  3. In the Social Security Number section, you may choose to enter your number; however, this is optional.
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  5. Complete the City, State, and Zip code fields accurately to ensure proper identification.
  6. Review the Worker’s Certification section carefully. If all statements are true, affix your signature and date it in the provided spaces.
  7. For employers, enter the Employer’s Name and Address as well as the Employer ID # if available. Ensure all information is accurate for compliance.
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