_________________Unemployment Action Center, Inc.

_________________
240 Mercer Street New York, NY 10012-1507 (212) 998-6568 Fax: (212) 995-4079

ACKNOWLEDGEMENT AND CONSENT

Re: Case # _________________ I, __________________________________, claimant in the above-referenced unemployment insurance claim, have been advised and understand that: (1) I will be represented by law students working as volunteer advocates with the Unemployment Action Center, Inc. (hereafter UAC) a student-run, non profit corporation. (2) These students are not lawyers and will represent me as lay advocates. (3) The UAC is not accountable to the Brooklyn Law School, Cardozo School of Law, Columbia University School of Law, Fordham University School of Law, Hofstra University School of Law, New York University School of Law or New York Law School. (4) Although the students who represent me may be enrolled in one of the abovementioned schools, they represent me in their individual capacities and are not accountable to the abovementioned schools. (5) Neither the schools nor any employees, faculty members, or agents of the schools supervise the students who represent me or participate in any way in any decisions about my claim. Students do not get academic credit from the schools for this work. (6) Brooklyn Law School, Cardozo School of Law, Columbia University School of Law, Fordham University School of Law, Hofstra University School of Law, New York University School of Law or New York Law School are in no way responsible for the representation provided by the UAC or by the students. (7) All services are provided free of charge. (8) Any decision to assist me in an appeal of an ALJ decision will be in the sole discretion of the UAC. (9) The UACs request for me to order a copy of my hearing transcripts does not obligate the UAC to write, or submit an appeal brief on my behalf. (10) Once the UAC reviews my hearing transcript they will contact me regarding what, if anything, can be done with my appeal. (11) The UAC represents me in order to further my legitimate claim. The UAC reserves the right to discontinue representing me if it is determined that I have misrepresented any material facts, requested the UAC to engage in conduct or take positions that the UAC disagrees with, failed to cooperate with the UAC in the preparation of the case, or engaged in any conduct which the UAC believes is harmful to its interests. (12) In the event that my hearing is adjourned, whether the UAC will represent me is solely at its discretion. Having been advised and understanding these facts, I consent to be represented by an advocate or advocates with the UAC. Signed: _____________________________ Date: ________________
Claimant's signature

I certify that I have truthfully and accurately translated this document and its explanation to the claimant. Signed: _____________________________ Date: ________________
Translator's signature A NON-PROFIT, TAX EXEMPT ORGANIZATION