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Application For Lump Sum Payment IC-32 - Ohio
|Application For Lump Sum Payment Form. This is a Ohio form and can be used in Industrial Commission Workers Comp .||
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MUST BE NOTARIZED THE INDUSTRIAL COMMISSION OF OHIO In the Matter of the Claim of _____________________________ Claim No. of ___________________________ } Application for Lump Sum Payment IMPORTANT: State the purpose, the exact amount needed and, if now know, the person or persons to whom payment is to be made and the exact amount to each. No lump sum payment will be made unless definite and complete information as to the purpose for which the money is desired is given in the application. AFFIDAVIT The applicant herein, , represents that he has heretofore filed claim with the Industrial Commission of Ohio for an award from the State Insurance Fund; that said Commission has awarded and ordered paid to h the sum of $ ; that pursuant to the rules of said Commission, said amount is being paid in bi-weekly installments. Said applicant hereby requests, because of special circumstances, that all or part of the remaining payments of the said award be commuted to a lump sum payment in the amount of $ following purposes: which the applicant desires for the Said applicant's reasons for requesting this lump sum payment are as follows: In the event that the lump sum payment applied for herein is made by the Industrial Commission of Ohio, either wholly or in part, the applicant requests and authority is hereby irrevocably given to the said Commission to disburse the lump sum payment directly to the person or persons to whom payment is now due or shall become due from the applicant, as set forth above or according to the tenor of this application and any order of said Commission hereinafter made in respect thereto. In the event this Lump Sum Payment is granted it will result in a permanent reduction of weekly benefits which shall continue for the life of the claim. Claimant (Number and Street) (City and State) (Zip) IMPORTANT: List your phone no. or a number where you can possibly be reached. Area Code No. SS:/ , being first duly sworn, says that the statements contained in the STATE OF OHIO, COUNTY OF foregoing Application for Lump Sum Payment are true. , 20 IC-32 Sworn to and subscribed before me, the undersigned authority, this OIC - 3003 (10/98) day of 2002 © American LegalNet, Inc.