and understand that this notice was provided to me in English because (check one): O my primary language is English O my primary language is but the New York Department of Labor does not offer this form in my primary language. Employee Signature Date Preparer Name and Title CONFIDENTIAL Page 6 Olt Man GI Int, YVVI.Pill

nd understand that this notice was provided to me in English because (check one): O my primary language is English O my primary language is , but the New York Department of Labor does not offer this form in my primary language. Employee Signature Date Preparer Name and Title r: nut ,,,,,,,AONFJPFATIOJAn. Minalenvni F1, 0