Fill and Sign the Sc Fee Workers Compensation Form

Yes No. Yes No. Yes No.Yes WCC File #       Carrier File #             Employer FEIN                                                                               If yes, where?       What are your spouse's wages?             How many people are dependent on you for support (include children and relatives)?       How much do you spend weekly for their support?                   Checking;       Rent No. Own. Rent or mortgage payment:       Payments:                   Fee Waived Waiver Rejected Other Disposition       South Carolina Workers' Compensation Commission P.O. Box 1715 1612 Marion Street Columbia, South Carolina 29202-1715 (803) 737-5700 Carrier Code # Claimant's Name SSN Employer's Name Address City State Zip Address City State Zip Home Phone # Work Phone # Insurance Carrier Preparer's Name Phone # 1 . Are you presently employed? (a) If yes, state the name and address of your employer and wages: (b) If no, where did you last work, when did you stop working, and what were your wages? (c) Is your spouse employed? (d) What is the total income of all working members of your household? 2. 3. List any money you have received in the past year other than that listed above and state from what source that money came (gift, inheritance, insurance). 4. Do you have a checking or savings account? If yes, what is the balance in each account? Savings. 5. Do you rent or own your home? 6. Do you own a car? 7. List the names of your creditors and amount of debt: To the best of my knowledge, the information above is true and accurate. I have made no attempt to misrepresent my financial condition. request that the fee for filing an Application for Commission Review be waived. Signature Date For official use only: Chair, S.C. Workers' Compensation Commission WCC Form # 32. Rev. Date 9/90 File this form with a Form 30, Application for Commission Review. Refer to R.67-701 through R.67-711 for additional information. Request to Waive Appeal Filing Fee.