Send original to the Workers' Compensation Court and 1 copy to All Other Parties of Record (Please type or print) Name of Claimant: (injured employee) Mailing Address: (include City, State & Zip) Social Security Number: Respondent: (Employer)
WORKERS COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918
THIS SPACE FOR COURT USE ONLY
Sec. 1: PERSONS IN HOUSEHOLD (please name the individual(s) and mark Spouse: Children:
whether they are claimed as a dependent by you. YES YES YES YES NO NO NO NO
Dependent? Dependent? ___________________________________________________ Dependent? ___________________________________________________ Dependent?
Others Are you claimed as a dependent by parent or guardian? If YES, please explain:
Sec. 2: FINANCIAL STATUS/ASSETS
C A S H B A N K B O N D S O T H E R
Cash on Hand: Bank Name: Bank Address: Account # : Checking or Savings: Amount in Account:____________________________________________________________________________________________________________________ _______ ___________________________________________________________________________________________________________________________ Bonds & Securities--Please Describe: Value: ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ All Other Possessions of Monetary Value: Please Describe (including tax refunds, notes, accounts receivable, etc.) Value __________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________ Name of Employer: Address of Employer: City State Zip Telephone # ( ) Earnings: Weekly Monthly Are you currently working? If Not Currently Employed, Name of Last Employer: Address of Last Employer: City State Amount: Zip Date of Last Employment:
Supplemental Income Sources (V.A. Soc. Security, Disability, Child Support etc.):
Is Amount Weekly or Monthly:
_______________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________ Home & Other Real Estate (please describe): Value Balance Owed Vehicle(s) (please describe): Value Balance Owed
______________________________________________________________ ______________________________________________________________ Personal Property (furniture, appliances, etc.): Value
Balance Owed Litigation you or your spouse have pending for recovery of money: Case # County ______________________________________________________________ ______________________________________________________________
Please fill out the remainder of the information on the reverse side of this Form
Sec. 3: FINANCIAL STATUS/LIABILITIES Charge or Open Accounts, please describe Balance Owed Name of Mortgagee/Landlord Monthly Payment If owned, amount owed _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Mortagee Name: Address: City: State: Zip:
Child Support Obligations
Other Debts (please describe)
_______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Sec. 4: OTHER YES YES NO NO Have you transferred or sold any assets since filing this workers' compensation claim? Have you retained counsel in this case or in any other pending workers' compensation claim?
Please list all other workers' compensation claims you have filed within the past 5 years:
Court Claim # Date of Award Total Amount of Award Of the Total Award, how much was for PPD? TTD? PTD?
Do you have any friends or relatives who are able and willing to assist you paying fees and costs? If so, have those persons been asked to help?
If a friend or relative has given previous financial assistance in this case, but no longer is able or willing to do so, an affidavit to that effect from that person shall be attached, stating why such help is no longer available. I further swear and affirm that I am without funds or other sources of income to pay an attorney or to pay for fees and costs associated with this case. I understand I am under a continuing obligation to keep this Court informed of any changes in my financial status and this Court may conduct another hearing to determine my indigent status at any time. I declare under penalty of perjury that I have examined this affidavit, and all statements contained herein, and to the best of my knowledge and belief, they are true, correct and complete. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony.
_______________________________________________________________ Signature of Applicant
I hereby certify that a true and correct copy of this affidavit was mailed to all other parties on the _______day of____________________, __________
Name of claimant's attorney if represented: Type or Print Name of Attorney: OBA # Mailing Address:
Telephone # ( )
A Hearing on the claimant's qualification as a pauper shall be held before the assigned trial judge prior to any trial on the merits or arguments before the Three-Judge Panel.