Datasets:
unstructuredio
/
SCORE-Bench

Dataset card Data Studio Files
xet
Community
2
text
stringlengths
0
2.18k
No
14. Have you applied for an award under Section 5 of the Radiation Exposure Compensation Act (RECA)? If yes, provide RECA Claim #:
--------------------------------------------------- Unstructured Handwriting Begin
42 - 42 - 4020
--------------------------------------------------- Unstructured Handwriting End
--------------------------------------------------- Unstructured Handwriting Begin
[x]
--------------------------------------------------- Unstructured Handwriting End
Yes [] No
15. Have you applied for an award under Section 4 of RECA? [] Yes
--------------------------------------------------- Unstructured Handwriting Begin
[x]
--------------------------------------------------- Unstructured Handwriting End
No
--------------------------------------------------- Unstructured Sub-Title Begin
Employee Declaration
--------------------------------------------------- Unstructured Sub-Title End
Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud to obtain compensation as provided under EEOICPA or who knowingly accepts compensation to which that person is not entitled is subject to civil or administrative remedies as well as felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both. Any change to the information provided on this form once it is submitted must be reported immediately to the district office responsible for the administration of the claim. I hereby make a claim for benefits under EEOICPA and affirm that the information I have provided on this form is true. If applicable, I authorize the Department of Justice to release any requested information, including information related to my RECA claim, to the U.S. Department of Labor, Office of Workers’ Compensation Programs (OWCP). Furthermore, I authorize any physician or hospital (or any other person, institution, corporation, or government agency, including the Social Security Administration) to furnish any desired information to the U.S. Department of Labor, Office of Workers’ Compensation Programs.
Employee Signature
--------------------------------------------------- Unstructured Handwriting Begin
Helena Wells
--------------------------------------------------- Unstructured Handwriting End
Date
--------------------------------------------------- Unstructured Handwriting Begin
02/11/2001
--------------------------------------------------- Unstructured Handwriting End
Resource Center Date Stamp
--------------------------------------------------- Unstructured Form End
--------------------------------------------------- Unstructured Page Footer Begin
--------------------------------------------------- Unstructured Page Number Block Begin
Page 1 of 2
--------------------------------------------------- Unstructured Page Number Block End
--------------------------------------------------- Unstructured Image Begin
Print Form
--------------------------------------------------- Unstructured Image End
--------------------------------------------------- Unstructured Image Begin
Save Form
--------------------------------------------------- Unstructured Image End
--------------------------------------------------- Unstructured Image Begin
Reset Form
--------------------------------------------------- Unstructured Image End
--------------------------------------------------- Unstructured Image Begin
Next Page
--------------------------------------------------- Unstructured Image End
Form EE-1
July 2024
--------------------------------------------------- Unstructured Page Footer End
--------------------------------------------------- Unstructured Plain Text Format 1.0.4
--------------------------------------------------- Unstructured Form Begin
--------------------------------------------------- Unstructured Title Begin
Application for Partial Payment
--------------------------------------------------- Unstructured Title End
--------------------------------------------------- Unstructured Sub-Title Begin
OMB Control Number: 9000-0012
Expiration Date: 2/28/2026
--------------------------------------------------- Unstructured Sub-Title End
--------------------------------------------------- Unstructured Sub-Title Begin
For Use by Prime Contractor or Subcontractor Under Contracts Terminated for the- Convenience of the Government.
--------------------------------------------------- Unstructured Sub-Title End
This Application Applies to (Check one) [] A Prime Contract with the Government
--------------------------------------------------- Unstructured Handwriting Begin
[x]
--------------------------------------------------- Unstructured Handwriting End
Subcontract or Purchase Order
Subcontract or Purchase Order Number(s)
--------------------------------------------------- Unstructured Handwriting Begin
427918972
--------------------------------------------------- Unstructured Handwriting End
--------------------------------------------------- Unstructured Sub-Title Begin
Contractor Who Sent Notice of Termination
--------------------------------------------------- Unstructured Sub-Title End
Name
--------------------------------------------------- Unstructured Handwriting Begin
Uber Defense Systems
--------------------------------------------------- Unstructured Handwriting End
Address (Include ZIP Code)
--------------------------------------------------- Unstructured Handwriting Begin
1042 Chain Bridge Rd, Fairfax, VA 22030
--------------------------------------------------- Unstructured Handwriting End
--------------------------------------------------- Unstructured Sub-Title Begin
If Contractor has Guaranteed Loans or has
Assigned Moneys due Under the Contract, Give
the Following:
--------------------------------------------------- Unstructured Sub-Title End
Name and Address of Financing Institution
(Include ZIP Code) ___
Name and Address of Guarantor (Include ZIP Code) ___
Name and Address of Assignee (Include ZIP Code) ___
Applicant