Arkansas > Workers Comp
Affidavit For Dependents Other Than Spouse Or Child SF-6 - Arkansas
| Affidavit For Dependents Other Than Spouse Or Child Form. This is a Arkansas form and can be used in Workers Comp . |
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Form SF-6 Rev. 1-1-2001 Authority: Ark. Code Ann. §11-9-527 ARKANSAS WORKERS' COMPENSATION COMMISSION SPECIAL FUNDS DIVISION 1515 West Seventh Street, Suite 219, Little Rock, AR 72201 501-682-5187 / 1-800-622-4472 (Toll-free) SF-6 AFFIDAVIT FOR DEPENDENTS OTHER THAN SPOUSE OR CHILD (Parent, brother, sister, grandparent, grandchild) Date (Field1) Beneficiary (Field2) Address (Field5) CERTIFIED MAIL Re: Claimant (Field3) - AWCC File No. (Field4) Under the provisions of Ark. Code Ann. 11-9-527, workers' compensation benefits are being paid to you as a dependent of (Field3). You will continue to receive these benefits until your death. We ask you to complete, sign, have notarized, and return this Affidavit to our office at the address above within thirty (30) calendar days. Failure to do so will result in suspension of your benefit checks. If you have questions, please call us at 501-682-5187 or 1-800-622-4472, ext. 25187 (toll-free). /s/ Death & Permanent Total Disability Trust Fund AFFIDAVIT I, (please print) , do certify that I was a dependent of (Field3), deceased, and have instructed family members or the executor/-trix of my estate to promptly notify the Trust Fund upon my death. Beneficiary's signature State of County of ) ) Subscribed and sworn to before me this _______ day of _______________________, 2________. My commission expires: Notary Public Ark. Code Ann. §11-9-106(a): "Any person or entity who willfu lly and kno wingly makes a ny mater ial false sta tement or repres entation , who wi llfully and kn owingly omits or conce als any m aterial in formation , or who w illfully and kn owingly employs any device, scheme, or artifice for the purpose of: obtaining any benefit or payment; defeating or wrongfully increasing or wrongfully decreasing any claim for benefit or payment; or obtaining or avoiding workers' compe nsation coverage or avoiding payment of the proper insurance premiu m, or who aids and abe ts for any of said purposes, under this chapter shall be guilty of a Class D felony. Fifty percent (50%) of any criminal fine imposed and collected under .. .. this section shall be paid and allocated in accordance with applicable law to the Death and Permanent Total Disability Trus t Fund adm inistered by th e Workers' C ompensat ion Comm ission." SF-6 2001 © American LegalNet, Inc.
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