Massachusetts > Workers Comp
Affidavit Of Indigence And Request For Waiver Of Section 11A(2) Fees 136 - Massachusetts
| Affidavit Of Indigence And Request For Waiver Of Section 11A(2) Fees Form. This is a Massachusetts form and can be used in Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
FORM 136 The Commonwealth of Massachusetts Department of Industrial Accidents Department 136 1 Congress Street, Suite100, Boston, Massachusetts 02114-2017 Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470 http://www.mass.gov/dia DIA Board # (If Known): AFFIDAVIT OF INDIGENCE AND REQUEST FOR WAIVER OF §11A(2) FEES All questions must be answered in full or the word "none" inserted. If additional space is needed for any answer, an attached sheet may be filed in addition to, but not in place of, the answer. Information contained herein will only be made available to the parties and other persons as allowed under state or federal law. Give monthly figures. To convert weekly to monthly figures, multiply the weekly amount by 4.3. I. INFORMATION ON EMPLOYEE'S CLAIM Employee's Name:__________________________________ Employee's Address: _______________________________ __________________________________________________ Marital Status & No. of dependents: ___________________ Workers' Comp. Insurer: _________________________ Social Security No. 1: _____________________________ Date of Injury: __________________________________ II. POVERTY AND ASSISTANCE QUALIFICATION [from SJC RULE 3:10 Section 1 (f)(i) and (ii)]: _____ (a) I receive one of the following types of public assistance: Aid to Families with Dependent Children (AFDC), Emergency Aid to Elderly, Disabled and Children (EAEDC), poverty related veterans' benefits, food stamps, refugee resettlement benefits, Medicaid, or Supplemental Security Income (SSI) or; _____ (b) I receive an annual income, after taxes, of 125% or less of the current poverty threshold referred to in M.G.L. c. 261 §27A (b). 2 III. MONTHLY INCOME FROM ALL SOURCES: A. EMPLOYMENT OR SELF-EMPLOYMENT 1. GROSS: a. Salary, Wages b. Tips, bonuses, self-employment income 2. 3. TOTAL (a plus b) DEDUCTIONS: c. d. e. f. g. 4. Federal Income Tax State Income Tax FICA/state or other retirement Union dues Business expense, if self-employed $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ Self $_______________ $_______________ $_______________ Spouse3 $_______________ $_______________ $_______________ TOTAL DEDUCTIONS (c through g) 5. ADJUSTED INCOME ( 2 minus 4) ---------------------------------------------------------1 2 Disclosing Social Security Number is voluntary. It will assist in the processing of your request. The 125% figures shall be available from the Department. The citation to §625 of the Economic Opportunity Act in M.G.L. c. 261, §27A, as recommended by St. 1980, c. 539, §5 has become §624. Pub. I. 88-425, title VI, §624 [42 U.S.C. §2971(d)]. As noted on "Affidavit of Indigency and Request for Waiver, Substitution or State Payment of Fees and Costs" From CIV. P. 90, in note 1, the 125% figure is substantially the same poverty standard used by legal services programs funded by the Federal Legal Services Corporation. 42 U.S.C. §2996(a)(2)(A)&(B). If there is a spouse, or person in substantially the same relationship, or parent (provided, in each instance, any such person lives in the same residence as the applicant and contributes toward the household's basic living costs), you must list income, amounts contributed by each to basic living costs, and liquid assets for each person(s), in Parts III, IV and V in the column labeled "spouse". 3 REPRODUCE AS NEEDED. Page 1 of 2 - Please complete reverse side. Form 136 - Revised 7/2010 American LegalNet, Inc. www.FormsWorkFlow.com B. INCOME FROM OTHER SOURCES: h. i. j. k. l. Workers' Compensation Social Security Long- or Short-term Disability Welfare Benefits Unemployment Compensation Self $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ Spouse Page 2 of 2 $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ m. Other sources (for example Rental Income, Pension Payments, Annuities, Alimony etc.) 6. TOTAL INCOME OTHER SOURCES (h -m) 7. TOTAL NET MONTHLY INCOME (5 PLUS 6) IV. BASIC LIVING COSTS (monthly): a. b. c. d. e. f. g. h. i. j. k. l. 8. 9. Rent Mortgage (Principal, Interest & Taxes) Food Clothing Utilities (Electricity/Gas) Heat Water/Sewer Telephone Transportation, e.g. Auto Loan, Auto Insurance Health Care/Health Insurance Support for Dependents Education Costs TOTAL COSTS ( a through l ) NET DISPOSABLE INCOME ( 7 minus 8 ) a. b. Cash on hand Cash in bank, mutual or other fund/account Savings Acct. #________________ Checking Acct. #________________ Real Estate Location _____________________ Stocks, bonds, etc. Motor Vehicle(s) Make _________________ Year______________ Fair Market Value $_______ - Loan $______ = Equity V. LIQUID ASSETS (Cash or Assets readily convertible to cash): c. d. e. $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ f. Other Liquid Assets TOTAL LIQUID ASSETS (a through f) I,________________________________, make this affidavit and request for a waiver and certify that I am unable to pay the filing fee mandated by c. 152 § 11A. I further certify that the information provided is true, complete, and accurate to the best of my ability, knowledge, and belief. I understand that some or all of this information is subject to, and must be accompanied by, verification.4 Signed under the pains and penalties of perjury: DATE(mm/dd/yyyy):___________________________ SIGNATURE:_____________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Other information relative to financial circumstances should be attached on separate sheets. 4 See "Standards and Proce
|
|||||||
