CPA/Lawyer Attestation LETTER
I am: A Certified Public Accountant (CPA), or An Attorney
Name: _______________________________________________________________________
Firm Name: __________________________________________________________________
Firm Address: ________________________________________________________________
Telephone Number: ___________________________________________________________
Professional License and/or Association Number(s): _________________________________
This letter of attestation is being provided on behalf of the following business entity:
Group’s Name: ________________________________________________________________
Group’s Address: ______________________________________________________________
Group’s Telephone Number: ____________________________________________________
Group Officer’s Name (from whom you received the written documentation reviewed in connection with this letter of attestation): __________________________________________
This group is a new business, which started on __________________ and will be filing tax documents, which will be sent to you at a future date.
I certify that this group has a New York situs, and is a:
> Sole Proprietorship, and the proprietor works a minimum of 20 hours per week.
> Partnership
> Corporation
> Limited Liability Company (LLC)
> S-Corp
> Other Type of Business Entity (explain) ___________________________________________
(Please attach copies of supporting documentation)
The following employees of this firm began working for this company on the following dates, and are working full-time (20 hours or more per week), and will be shown on future tax documents which will be provided to you.
Name Start Date Name Start Date
________________________ ________ ___________________ _________
________________________ ________ ___________________ _________
I hereby certify that the information I have stated above are true statements based on documentation provided to me. I hereby make this certification to induce X Company to offer health insurance coverage to this group based upon the information contained in my certification. I understand that X Company will retain this letter and any attached materials without regard to the acceptance or non-acceptance of the group’s application for coverage.
Signature:_________________
Date: ____________________