Free Questions and Affidavit Regarding Lost Income - Affidavit Form B (WCT-3) - Missouri


File Size: 109.4 kB
Pages: 3
Date: December 26, 2007
File Format: PDF
State: Missouri
Category: Workers Compensation
Author: es3375
Word Count: 470 Words, 2,935 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dolir.mo.gov/wc/forms/wct-3-ai.pdf

Download Questions and Affidavit Regarding Lost Income - Affidavit Form B (WCT-3) ( 109.4 kB)


Preview Questions and Affidavit Regarding Lost Income - Affidavit Form B (WCT-3)
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION TORT VICTIMS' COMPENSATION

QUESTIONS AND AFFIDAVIT REGARDING LOST INCOME AFFIDAVIT FORM B

3315 W. Truman Blvd. P.O. Box 58 Jefferson City, MO 65102-0058 (573) 751-4231

File No: Claimant's Name: (Please type or print your answers. You may use additional sheets if necessary.) I,
(name of undersigned claimant)

, as part of my claim against the Missouri Tort Victims'

Compensation Fund, hereby answer the following questions truly, accurately and completely. 1. Are you claiming a past loss of wages, salary, or income from one or more employers (not including selfemployment, employment as an independent contractor, or from a business or venture in which you have an ownership interest)? Yes No If yes, for each employer, state: a. Name, address and telephone number of employer; b. Inclusive dates of income loss; c. Medical and/or other reasons for inability to work; and d. Amount of wages, salary or income lost, and how calculated. Provide copies of all documents supporting your answers. Failure to provide documentation may delay the evaluation of your claim.

WCT-3 (08-04) AI

2. Are you claiming a past loss of income from self-employment, employment as an independent contractor, or from a business or venture in which you have an ownership interest? Yes No If yes, state: a. Nature of self-employment, or other business or venture; b. Trade name ("d/b/a"), if applicable; c. Share of your ownership interest; d. Names of other owners and their respective ownership shares; e. Inclusive dates of income loss; f. Medical and/or other reasons for income loss; and g. Amount of income lost, and how calculated. Provide copies of all documents supporting your answers. Failure to provide documentation may delay the evaluation of your claim.

3. Are you claiming a continuing or future loss of income? a. Anticipated duration of such loss of income;

Yes

No If yes, state:

b. Medical and/or other reasons for such anticipated loss of income; and c. Amount of such anticipated loss of income, and how calculated. Provide copies of all documents supporting your answers. Failure to provide documentation may delay the evaluation of your claim.

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4. Are you claiming a future loss of earning capacity?

Yes

No If yes, state:

a. Medical and/or other reasons for such anticipated future loss of earning capacity; and b. Dollar amount claimed for such loss of earning capacity and how calculated. Provide copies of all documents supporting your answers. Failure to provide documentation may delay the evaluation of your claim.

Oath or affirmation. I,
(print name)

, under oath or affirmation,

state that the foregoing answers, statements and representations are true and correct to my best knowledge and belief, subject to the penalties of making a false affidavit or declaration.

Signature

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