Arkansas > Workers Comp
Guardianship Affidavit Court-Appointed Non-Minor SF-2 - Arkansas
| Guardianship Affidavit Court-Appointed Non-Minor Form. This is a Arkansas form and can be used in Workers Comp . |
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Form SF-2 Rev. 1-1-2001 Authority: Ark. Cod e Ann. §§ 11-9-527,-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-2 GUARDIANSHIP AFFIDAVIT (Court-Appointed, Non-Minor) Date (Field1) Address (Field3) RE: (Field2) CERTIFIED MAIL Workers' compensation benefits are being paid to you in your capacity as court-appointed guardian of the estate of _______________________________________________ (the adult "ward"). You will receive those benefits until termination of your duties as the guardian, the death of the ward, or upon termination of the ward's eligibility. Please complete, sign, and have notarized the following Affidavit. This form must be returned to our office within the next thirty (30) calendar days. Failure to do so will result in a suspension of benefits. If you have any questions, please call 501-682-5187 or (toll-free) 1-800-622-4472. /s/ Death and Permanent Total Disability Trust Fund AFFIDAVIT I, ____________________________________________, do hereby certify that I have been duly court-appointed and remain the guardian of the estate of ______________________________________ ("ward"). I certify that I will promptly notify the Trust Fund of any modification or termination of this guardianship, or the ward's death. State of ____________________ ) County of __________________ ) Signature SUBSCRIBED AND SWORN TO before me on the ____ day of ____________________, 2_______. Notary Public My Commission Expires: Ark. Code Ann. §11-9-106(a): " Any person or entity who wil lfully and knowingly makes any material false statement or representation, who willfully and knowin gly omits or conceals any material information, or who willfully and knowingly 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 avoid ing 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-2 2001 © American LegalNet, Inc.
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