Employer's Knowledge Statement
The employer is required to submit a notarized knowledge affidavit containing information outlined in the following format:
On (Date of first knowledge), I (Name), the (Title) for (Employer), learned that (Employee) SSN (SSN) had (Type of prior impairment). I received this information in the following manner: (Describe). I considered it a permanent physical impairment because: (Describe). In addition, I considered the impairment likely to be a hindrance to employment because: (Describe).
If this affidavit is prepared by someone other than the appropriate employer representative, please identify: (Name).
NOTICE TO EMPLOYER:
If this document is pre-prepared and submitted to you for signature, carefully review this document to make sure the Information outlined is consistent with your knowledge of the prior impairment.
I, the undersigned employer representative, hereby provide the above information under oath.
(Employer Representative) (Title) (Telephone Number) (Date) (Notary Public Signature) (Expiration Date of Notary Status).
IF YOU HAVE A DISABILITY AND NEED ASSISTANCE IN COMPLETING THIS FORM, PLEASE CONTACT THE SUBSEQUENT INJURY TRUST FUND’S ADA COORDINATOR AT MARQUIS II TOWER, SUITE 1250, 285 PEACHTREE CENTER AVENUE NE, ATLANTA, GA 30303, TELEPHONE NO. (404) 656-7000; FAX NO. (404) 656-7100; TDD NO. (404) 656-7162 WEBSITE: www.sitf.georgia.gov
IMPORTANT : See Reverse Side for Instructions
1. The affiant must be someone who has firsthand knowledge of the worker’s pre-existing condition such as an individual in an executive, personnel, or personnel-advisory capacity, or, if an employer is subject to the Americans With Disabilities Act, the designated custodian of (medical) records.
2. Attach any documentation or records that were in the employer’s possession prior to the subsequent injury. If you attach documents, these must be accompanied by certification on employer’s letterhead that said documents were contained in employer’s files.
Any reports specifically referred to in the affidavit must be attached and certified.
3. The employer should identify the actual date of knowledge of the prior impairment.
4. The employer, if possible, should list any individuals either currently or formerly working for the employer who may have firsthand knowledge of the employee’s pre-existing disability.
a. Name Address Telephone No.
b. Name Address Telephone No.
c. Name Address Telephone No.