Lien Disclosure Form {116C}

FORM 116C The Commonwealth of Massachusetts Department of Industrial Accidents Department 116C Lafayette City Center, 2 Avenue de Lafayette, Boston, MA02111 - 1750 Info . Line (800) 323 - 3249 Inside Mass. / (857) 321 - 7470 Outside Mass. 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 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 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 116 C Revised 7 / 2019 American LegalNet, Inc. www.FormsWorkFlow.com