Massachusetts > Workers Comp
Lien Disclosure Form 116C - Massachusetts
| Lien Disclosure Form Form. This is a Massachusetts form and can be used in Workers Comp . |
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FORM 116C The Commonwealth of Massachusetts Department of Industrial Accidents Department 116C 1 Congress Street, Suite 100, 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): LIEN DISCLOSURE FORM TO BE COMPLETED BY THE EMPLOYEE I, _____________________________________________________, (Print Name) hereby certify that, to the best of my knowledge, there are no outstanding liens or claims for reimbursement out of the proceeds of my workers' compensation settlement by the Department of Transitional Assistance, Department of Revenue Child Support Enforcement Unit, Veterans Services, prior counsel, or any medical, dental, hospital or disability income provider. My workers' compensation DIA Board number(s) is (are): ______________________________________________ SIGNED UNDER THE PAINS AND PENALTIES OF PERJURY. ____________________________________________ Signature of Employee _____________________________________________ Address of Employee _____________________________________________ Social Security Number* _____________________________________________ Date *Disclosure of Social Security Number is voluntary. It will assist in the processing of this document. Reproduce as needed. FORM 116C Revised 7/2010 American LegalNet, Inc. www.FormsWorkFlow.com
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