COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS' COMPENSATION APPLICATION FOR INDIGENT DETERMINATION (IME) Instructions to the Claimant: You have the right to submit an Application for Indigent Determination (IME) if you believe that you are unable to pay the fee(s) required to obtain a Division Independent Medical Examination. You must complete this Application and sign the affirmation on page four. The original Application shall be filed with the Office of Administrative Courts at 1525 Sherman Street, 4th Floor, Denver, CO 80203 and a copy sent to all parties in the case. Claimant: Employer: Insurance Carrier: Household status of claimant: * Single Separated Common Law Bank Accounts or other financial Accounts: Checking: Savings: Other: At At At Account balance: $ $ $ $ Amt. Owed: $ $ Amt. Owed: Amt. Owed: $ Married Divorced W.C. Number: Social Security Number: Carrier Number: Number of dependents: Spouse Children Other Ages of children Amount of cash on hand: $ Estimated Value of property and real estate owned: $ Vehicles owned: Year: Year: Make: Make: Value: Value: Gross monthly income of all household members: * Earnings - claimant: Earnings - spouse Earnings - other members Stock, Bonds, Investments $ $ $ $ Monthly expenses of household: Rent/House payment $ Utilities $ Food $ Clothing $ * Income from roommates should not be included unless the relationship between the applicant and the roommate is such that the applicant can access or use the roommate's income. It follows that if a roommate's income is not included, the applicant should list only his/her individual expenses. WC035 IME 08/15 Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Gross monthly income of all household members (cont'd): List other sources of income for household members. Include income such as AFDC, unemployment, workers' compensation, public assistance, social security, retirement pension, etc. $ $ $ $ Value of non-cash income, e.g., room & board in exchange for work performed. $ Total household income $ Monthly expenses of household (cont'd): Alimony/Child support Medical/Dental Bills Installment payments (including credit cards) Other $ $ $ $ Total monthly expenses: $ The following income guidelines apply when determining whether you are indigent for the purposes of this proceeding. See Workers' Compensation Rule 11-11 for more information. Monthly Income Monthly Income Yearly Income Yearly Income Family Size Guidelines Guideline plus 25% Guideline Guideline plus 25% 1 $1,128 $1,410 $13,538 $16,922 2 $1,518 $1,897 $18,213 $22,766 3 $1,907 $2,384 $22,888 $28,609 4 $2,297 $2,871 $27,563 $34,453 5 $2,686 $3,358 $32,238 $40,297 6 $3,076 $3,845 $36,913 $46,141 7 $3,466 $4,332 $41,588 $51,984 8 $3,855 $4,819 $46,263 $57,828 * For family units with more than eight members, add $390 per month for "monthly income" or $4,675 per year for "yearly income" for each additional family member. ADDITIONAL FINANCIAL INFORMATION In this proceeding the administrative law judge may consider additional information about your financial status that is not otherwise listed in this Application. You may describe in the space below any other circumstances affecting your current financial condition that you would like the judge to review when considering whether you are indigent and/or unable to pay for the Division IME. You may attach additional pages or documents if necessary. WC035 IME 08/15 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com ADDITIONAL FINANCIAL INFORMATION (continued) Please note: You must send a copy of this application to the insurance company, self-insured employer or uninsured employer and all attorneys. Remember to complete the reverse side of this page before filing this application. WC035 IME 08/15 Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com If further information or clarification is needed, it may be necessary for the Office of Administrative Courts to contact you. Please provide your address and phone number below: Phone Number Street/P.O. Box City, State, Zip If claimant is represented by an attorney, please provide name and address of attorney below: Attorney Name Street/P.O. Box City, State, Zip Phone Number Fax Number Email Address AFFIRMATION I certify the information contained in this application is true and correct. Claimant Signature If, for the purpose of obtaining any order, benefit, award, compensation, or payment under the provisions of articles 40 to 47 of [title 8], either for self-gain or for the benefit of any other person, anyone willfully makes a false statement or representation material to the claim, such person commits a class 5 felony and shall be punished as provided in Section 18-1.3-105, C.R.S., and shall forfeit all right to compensation under said articles upon conviction of such offense. (Section 8-43-402, C.R.S.) CERTIFICATE OF MAILING Copies of this document were placed in the U.S. mail or delivered to the following parties this , 20 . day of List the names and addresses of all persons copied: Insurance Carrier or Self-Insured Employer: Attorney for Insurer/Employer: Office of Administrative Courts 1525 Sherman Street, 4th Floor Denver, CO 80203 Copier's Signature: WC035 IME 08/15 Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com