Fill and Sign the Affidavit of Self Employed Independent Contractor Form

Affidavit of Independent Contractor Regarding Loss of Wages as Proof of Damages in a Personal Injury Suit STATE OF ______________________ COUNTY OF ___________________________ _______________________________, being duly sworn, deposes and says: 1. During the period time from _____________________________ (date of injury) to _____________________________ (date of recovery), I worked as an Independent Contractor as a _____________________________ (name of profession). My average gross income for such a period of time is $__________________ based on the last two years of earnings. 2. On the ____ day of ____________, I __________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ (e.g., slipped on one of the flights of stairs leading to the first floor of the Airport where I was going to retrieve my luggage from a flight from Atlanta). 3. As a result of this injury, I missed _______days of work, resulting in a loss of earnings in the amount of $___________. ____________________________________ STATE OF ___________________ COUNTY OF ____________________ Personally appeared before me, the undersigned authority in and for the aforesaid jurisdiction, the within-named _________________________, who, after having been first duly sworn, stated on oath that the matters and facts set forth in the above and foregoing Affidavit are true and correct as therein stated.SWORN to and subscribed before me, this the day of ______________, 20____. ________________________________________ Notary Public My Commission Expires: