TLC Settlement Authorization Form **_**_**

Aloysee Heredia Jarmoszuk, Commissioner

Mohammed Akinlolu, Asst. Commissioner

Prosecution Unit

**-** **** ******, *** Floor

Long Island City, NY 11101

+1-718-***-****

SETTLEMENT AUTHORIZATON FORM

In order to have an attorney or representative settle a summons with TLC on your behalf, you and the attorney or representative must complete this form. Please fill in all fields and retain a copy of the completed form for your records. TLC does not endorse or qualify any attorneys or representatives.

CERTIFICATION OF RESPONDENT

I,, certify that I am the respondent and/or owner or principal of the respondent entity named in the TLC summons(es) listed below. I hereby authorize, an attorney or representative, to enter into a settlement agreement with TLC on my behalf in resolution of the summons(es) listed below. I further certify that the attorney or representative has informed me of all of the following: 1) The attorney or representative is not an employee of TLC. 2) I have a right to a hearing and am not required to settle my summons(es) with TLC. 3) I may appear at TLC to settle my summons(es) without an attorney or representative. 4) I will be responsible for the payment of any fines as listed on the settlement agreement(s). 5) All TLC settlement agreements include a guilty plea that will count toward the calculation of future penalties. Summons # License #

/ / Respondent Signature Print Name Date

CERTIFICATION OF ATTORNEY/REPRESENTATIVE

I,, hereby certify that I have been authorized by, the respondent and/or owner or principal of the respondent entity named in the above TLC summons(es), to enter into a settlement agreement with TLC in resolution of the above summons(es). I also acknowledge that I am aware of and have explained all of the terms of the settlement agreement(s) to the above-named respondent. Furthermore, I have been warned that any willful false statements made on or in connection with this form are punishable by fine or imprisonment, or both, under New York Penal Law Section 175.30. I declare that all statements made of my knowledge are true, and all statements made based on information and belief are believed to be true. / / Attorney/Representative Signature Print Name Date