Oklahoma > Workers Comp

Paupers Affidavit CC-Form-99 - Oklahoma

Paupers Affidavit Form. This is a Oklahoma form and can be used in Workers Comp .
 Fillable pdf Last Modified 3/18/2014
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CC-FORM-99 Send original to: or er Co en a on Co i ion and 1 o to All Ot er ar e o Re ord (Please type or print) WORKERS COMPENSATION COMMISSION 1915 NORTH STILES AVENUE OKLAHOMA CITY, OK 73105 THIS S ACE FOR COMMISSION USE ONLY Full Na e o Clai ant: (Injured E lo ee) Mailing Addre : (in lude Cit , State & Zi ) So ial Se urit Nu ber: (LAST 4 DIGITS ONLY) XXX-XX-___________________ Re ondent: (E lo er) PAUPER'S AFFIDAVIT COMMISSION FILE NO. Sec. 1: PERSONS IN HOUSEHOLD (please name the individual(s) and mark S ou e: De endent? whether they are claimed as a dependent by you. YES NO C ildren: C ildren: C ildren: De endent? De endent? De endent? YES YES YES NO NO NO Ot er : De endent? YES NO Are ou lai ed a a de endent b arent or guardian? De endent? YES NO I YES, lea e ex lain: ___________________________________________________________________________________________________________________________ Sec. 2: FINANCIAL STATUS/ASSETS C A S H B A N K B O N D S O T H E R Ca on Hand: Ban Na e: Ban Addre : A ount # : C e ing or Saving : A ount in A ount:__________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ Bond & Se uri e -- lea e De ribe: Value: _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ All Ot er o e ion o Monetar Value: lea e De ribe (in luding tax re und , note , a ount re eivable, et .) Value _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ Na e o E lo er: Addre o E lo er: Cit State Zi Tele ( one # ) Earning : ee l Mont l Are ou urrentl wor ing? I Not Currentl E lo ed, Na e o La t E lo er: Addre o La t E lo er: Cit State Zi Date o La t E lo ent: Su le ental In o e Sour e (V.A. So . Se urit , Di abilit , C ild Su ort et .): A ount: I A ount ee l or Mont l : ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ _ Ve i le( ) ( lea e de ribe): Value Balan e Owed Ho e & Ot er Real E tate ( lea e de ribe): Value Balan e Owed ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Li ga on ou or our ou e ave ending or re over o one : er onal ro ert ( urniture, a lian e , et .): Value Balan e Owed Count ______________________________________________________________________ Ca e # ______________________________________________________________________ ______________________________________________________________________ Created 2-1-14 Please ll out the remainder o the in orma on on the reverse side o this Form American LegalNet, Inc. www.FormsWorkFlow.com Sec. 3: FINANCIAL STATUS/LIABILITIES Na e o Mortgagee/Landlord Mont l a ent I owned, a ount owed C arge or O en A ount , lea e de ribe Balan e Owed _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Mortgagee Na e: Addre : Cit : State: Zi : C ild Su ort Obliga on Mont l a ent ______________________________________________________________________ Ot er Debt ( lea e de ribe) Mont l A ount Balan e Owed _______________________________________________________________________ _______________________________________________________________________ Sec. 4: OTHER YES YES NO NO Have ou tran erred or old an a et Have ou retained oun el in t i in e ling t i wor er o en a on lai ? o en a on lai ? a e or in an ot er ending wor er lea e li t all ot er wor er Commission Claim # o en a on lai ou ave led wit in t e a t 5 ear : O the Total Award, how much was or Permanent Par al Disability Date o Award Total Amount o Award Temporary Total Disability Permanent Total Disability YES NO Do ou ave an riend or rela ve w o are able and willing to el ou a ee and o t ? YES NO I o, ave t o e er on been a ed to el ? I a riend or rela ve a given reviou nan ial a i tan e in t i a e, but no longer i able or willing to do o, an affidavit to t at e e t ro ta ng w t e el i no longer available. t at er on all be a a ed, I urt er wear and affir t at I a wit out und or ot er our e o in o e to a an a orne or to a or ee and o t a o iated wit t i a e. I under tand I a under a on nuing obliga on to ee t e Co i ion in or ed o an ange in nan ial tatu and t e Co i ion a ondu t anot er earing to deter ine indigent tatu at an e. I declare under PENALTY OF PERJURY that I have examined this affidavit, and all statements contained herein, and to the best of my knowledge and belief, they are true, correct and complete. I hereby cer fy that a true and correct copy of this AFFI A IT was mailed to all other par es on the date noted below. Administra ve Workers' Compensa on Act, A O.S., (A)(1)(a): An er on or en t w o a e an aterial al e tate ent or re re enta on, w o will ull and nowingl o it or on eal an aterial in or a on, or w o e lo an devi e, e e, or ar e, or w o aid and abet an er on or t e ur o e o : (1) obtaining an bene t or a ent ... all be guilt o a elon ." Any person who commits workers compensa on fraud, upon convic on, shall be guilty of a felony punishable by imprisonment, a fine or both. Signed this ______________ day o _____________________________________________ , __________________. _______________________________________________________________________________________________ Signature o A li ant Na e o Clai ant A orne , i re re ented: T e or rint Na e o A orne : OBA # Mailing Addre : Cit State Zi Tele ( one # ) A hearing on the claimant's uali ca on as a pauper shall be held be ore the assigned ad
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