Fill and Sign the Payment of Filing Fees Form

BEFORE THE IOWA WORKERS’ COMPENSATION COMMISSIONER ________________________________________________________________________ : :: Claimant, : : : File No. _____________ vs. : : APPLICATION TO DEFER: : PAYMENT OF FILING FEES, Employer, : : FINANCIAL AFFIDAVIT AND ORDER: and : :::: Insurance Carrier, : Defendants. : _________________________________________________________________________ I, the undersigned, hereby request the Iowa Workers’ Compensation Commissioner to accept for filing my Original Notice and Petition without prepayment of filing fee(s). I hereby state that if I am unable to defer the filing fee(s) in this matter, I would be unable to maintain this action, and there is no reasonable alternative means for procuring the filing fee(s). I understand that if the Original Notice and Petition is accepted for filing without prepayment of the filing fee(s), provision for the payment of the filing(s) must be included in any settlement submitted to the Workers’ Compensation Commissioner for approval, or taxed as costs as part of a hearing on my petition. In support of my request, I hereby submit the following affidavit under oath (attach additional sheets if necessary). 2 Current mailing address:_____________________________________________ Current phone number:______________________________________________ Age:________________ Marital status: Single______Married_______Divorced_______Widow(er)_______ Name of spouse:____________________Live with spouse? Yes____No____ If no, length of separation from spouse:_______________________________ Number and ages of dependents:_______________________________________________________________ INCOME: Your occupation:_______________________ Are you presently working? Yes____ No____ If yes: Present Employer:_____________________________ Address:______________________________________ Weekly take-home earnings: $______________ Weekly gross earnings: $______________ Earned income for past 12 months: $___________ If no: Are you currently receiving weekly workers’ compensation benefits of any kind? Yes____No____ If yes, amount: $_________ Total received in last 12 months: $___________________ Are you currently receiving any other kind of disability income, such as sick leave, social security disability, or private disability insurance payments? If so, state amount: $_________per________ Are you receiving child support for any dependents?______________ If so, how much? $______________per____________________. List all other sources and amounts of income, in your name, name of spouse or jointly shared with another, including spouse’s salary (net wages), pensions, bonds, stocks, securities, private business, farming, insurance, retirement benefits, social security benefits, lawsuits or settlements, gifts or others:______________________________. Unemployment compensation, heating assistance, food stamps, ADC or welfare relief, in your name, spouse’s name or jointly shared with another: $_________per __________ List any anticipated tax refunds in the next 6 months and the amount thereof:_______ Whether or not you are presently working, state your income from all sources for the past 12 months: $______________________. 3 ASSETS: Bank with:____________________________Address:____________________________ Balance personal bank accounts (checking and savings): $_____________ Balance accounts in name of spouse: $________________ Balance joint accounts with spouse: $_________________ Balance joint accounts with any other person: $_________ List the amount of cash currently in your possession or available to you, including cash on your person, at your place of residence, in safety deposit boxes, or in any other location:$________________________________ Real Estate: Property 1: Type (residence, farm, etc): __________________ Address or location: __________________________ Market value: ________________________________ Insured value:________________________________ Insured with: _____________________________ Address:__________________________________ Tax value:___________________________________ When purchased: ____________________________ Purchase price: ______________________________ Present owners besides yourself: ___________ ____________________________________________ Amount of mortgages or liens on property: ______________________________ Is this a homestead? Yes ____ No ____ Property 2: Type (residence, farm, etc.): __________________ Address or location: _________________________ Market value: _______________________________ Insured value:_______________________________ Insured with:___________________________ Address:_______________________________ Tax Value:__________________________________ When purchased:____________________________ Purchase price:______________________________ Present owners besides yourself: _____________ ____________________________________________ Amount of mortgages or liens on property: __________________________________ Is this a homestead? Yes ____ No ____ If more than two properties are owned, list others on a separate sheet and attach to this form. Is such a sheet attached? Yes_____ No____ 4 Motor vehicles: Give make, year, present value, amount owing thereon, if any, and whether registered or titled in your name, name of spouse or jointly with another of all vehicles in which you have an ownership interest: Vehicle 1: Description_______________________________ Value $____________ Emcumbrance: $_________________ Lienholder: _____________________ Address: _______________________ Vehicle 2: Description________________________________ Value $ ___________ Encumbrance $ __________________ Lienholder: ______________________ Address: ________________________ Other assets in your name, in the name of your spouse, or jointly owned with someone else, including furniture, appliances, televisions, stereos, videotape equipment, photographic cameras, jewelry, furs, trust funds, notes, bonds, stocks, savings certificates, securities, cash value of life insurance, equipment or machines, boats, aircraft, motorcycles, campers or recreational vehicles, coin or stamp or any other collections with a recognized market value, livestock, purebred animals, harvested or unharvested crops, etc. and value of each: ________________________________________________________________________________ ________________________________________________________________________________ Are you a beneficiary or heir in the estate of a person deceased? Yes___ No___ Does anyone owe you money or have any property belonging to you? If so, give details in full:___________________________________-___________________________________________________ Do you have a judgment against anyone? If yes, give name, date, court and amount: ________________________________________________________________________________ EXPENSES: Average monthly living expense: Food: $________________per___________ Housing: $_____________per___________ Utilities/telephone: $____________per__________ Clothing: $____________per____________ Transportation: $_______________per__________ Medical (paid by you): $_________per__________ Installment payments: $_________per__________ Payable to:___________________________ $__________per___________ Other: $__________________________________________ 5 I, the undersigned, being duly sworn under oath, certify under penalty of perjury and pursuant to the laws of the State of Iowa that the foregoing statements are true and correct to the best of my knowledge, and are made in support of my request that my Original Notice and Petition be filed without payment of a filing fee at the time of filing. I understand that a knowingly false statement in this affidavit may constitute a fraudulent practice under Iowa Code section 714.8(2) and may subject me to criminal penalties, including imprisonment, fine or both. I also hereby authorize the Iowa Workers’ Compensation Commissioner or any of the Commissioner’s designees to investigate any statements contained herein, and I hereby waive any privilege and release any information to the Commissioner or the Commissioner’s designees to facilitate an investigation of the truth of this affidavit. I further state that I am the claimant in the above-entitled action, that I have read the above Application and understand its contents, and that the statements it contains are true to the best of my knowledge. ______________________________________ Claimant Subscribed and sworn to by ___________________________________ before me, a Notary Public, this _____ day of ________________________________, ____. ______________________________________ Notary Public for the State of Iowa 6 ORDER Claimant’s request for deferral of filing fee(s) is approved. Claimant’s Petition and Original Notice may be filed without prepayment of filing fee(s). Payment of the filing fee(s) shall be deferred until final disposition of this proceeding. Signed and filed this ________day of _______________________, __ ___. ______________________________________ DEPUTY WORKERS’ COMPENSATION COMMISSIONER Claimant’s request for deferral of filing fee(s) is denied. Claimant shall forward the appropriate filing fee(s) within 14 days of this Order, or claimant’s Petition will be dismissed without prejudice and without entry of further order. Signed and filed this ________day of _______________________, __ ___. _____________________________________ DEPUTY WORKERS’ COMPENSATION COMMISSIONER The information provided will be open for public inspection under Iowa Code § 22.11. 14-0075 (7/99)