Arkansas > Workers Comp
Guardians Affidavit-Dependent Children SF-5 - Arkansas
| Guardians Affidavit-Dependent Children Form. This is a Arkansas form and can be used in Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Form SF-5 Rev. 1-1-2001 Authority: Ark. Code Ann. §11-9-801 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-5 GUARDIAN'S AFFIDAVIT - DEPENDENT CHILD(REN) Re: File name (Field1) AWCC File No. (Field2) (Please read the cover letter from the Death & Permanent Total Disability Trust Fund that came with this Affidavit before completing the Affidavit.) AFFIDAVIT I, of the estate(s) of the dependent(s) named below of , hereby certify that I am the lawful legal guardian (deceased), that the information given about the child(ren) is correct, and I will promptly notify the Trust Fund of any change in my court-appointed guardianship or physical custody of any named dependents. (Check if used: G Additional dependent children are listed on the back of this sheet.) Dependent (name) Name of person or agency child currently lives with is currently living in the household of: That person's relationship to child Address City State ZIP Guardian's home telephone Guardian's work telephone, if any Name and place of work, if any Name of school this child currently attends, if any School telephone n umber Current grade level Guardian's signature State County ) ) Subscribed and sworn to before me this ______ day of __________________, 2_________. My commission expires: Notary Public Ark. Code Ann. §11-9-106(a): "Any pers on or ent ity who w illfully and kn owingly makes a ny mater ial false sta tement or repres entation , who wi llfully and kno wingly omits or conce als any m aterial in formation , or who w illfully and kn owingly em ploys any d evice, sc heme, o r artifice for the pur pose of: obtaining any benefit or payment; defeating or wrongfully increasing or wrongfully decreasing any claim for benefit or payment; or obtaining or avoiding workers' compensation coverage or avoiding payment of the proper insu rance premium, or who a ids and abets 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 Permanen t Total Disability T rust Fund a dminister ed by the W orkers' Comp ensation C ommissio n." SF-5 2001 © American LegalNet, Inc. AWC C FOR M SF-5 GUARDIAN'S AFFIDAVIT DEPENDENT CHILDREN - CONTINUATION SHEET 2. Dependent (name) is currently living in the h ousehold of: Name o f person or agency child currently lives with That person 's relationship to child Address City State ZIP Child's home telephone Work telephone, if any Name and place of work, if any Name of school this child currently attends, if any School telephone number Current grad e level 3. Dependent (name) is currently living in the h ousehold of: Name o f person or agency child currently lives with That person 's relationship to child Address City State ZIP Child's home telephone Work telephone, if any Name and place of work, if any Name of school this child currently attends, if any School telephone number Current grad e level 4. Dependent (name) is currently living in the h ousehold of: Name o f person or agency child currently lives with That person 's relationship to child Address City State ZIP Child's home telephone Work telephone, if any Name and place of work, if any Name o f school this child currently attend s, if any School telephone number Current grad e level 5. Dependent (name) is currently living in the h ousehold of: Name o f person or agency child currently lives with That perso n's relationship to child Address City State ZIP Child's home telephone Work telephone, if any Name and place of work, if any Name of school this child currently attends, if any School telephone number Current grad e level SF-5 2001 © American LegalNet, Inc.
|
|||||||
