MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION TORT VICTIMS' COMPENSATION
QUESTIONS AND AFFIDAVIT REGARDING DUE DILIGENCE IN ENFORCING THE JUDGMENT AFFIDAVIT FORM D
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. Have you obtained a final judgment against the tortfeasor? Comment: Yes No
If no, do not continue with this form. Instead, complete Form WCT-4, Questions and Affidavit Regarding Waiver of Final Judgment Requirement Affidavit Form C. 2. What was the date the judgment became final? 3. What efforts have been made by you or on your behalf to enforce or collect upon the final judgment? Answer in detail, including dates. Attach copies of all documents evidencing attempts at execution, attachment, garnishment, sequestration, results of asset searches, and other similar documents.
Oath or affirmation. I,
, 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.
WCT-5 (08-04) AI