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Affidavit For Dependents Other Than Spouse Or Child Form. This is a Arkansas form and can be use in Workers Comp.
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Tags: Affidavit For Dependents Other Than Spouse Or Child, SF-6, Arkansas Workers Comp,
ARKANSAS WORKERS’ COMPENSATION COMMISSION
Form SF-6
Rev. 1-1-2001
SPECIAL FUNDS DIVISION
Autho rity:
Ark. Code Ann.
§11-9-527
SF-6
501 Woodlane Drive, Ste. 101, Little Rock, AR 72201
501-682-5187 / 1-866-880-8444 (Toll-free)
AFFIDAVIT FOR DEPENDENTS OTHER THAN SPOUSE OR CHILD
(Parent, brother, sister, grandparent, grandchild)
Date:_____________________
Re: ____________________________
(Date Mailed)
Claimant - AWCC File No.
_________________________
Dependent's Name
_________________________
Address
_________________________
CERTIFIED MAIL
Under the provisions of Ark. Code Ann. 11-9-527, workers’ compensation benefits are being paid to you as
a dependent of . You will continue to receive these benefits until your death.
We ask you to complete, sign, have notarized, and return this Affidavit to our office at the address above
within thirty (30) calendar days. Failure to do so will result in suspension of your benefit checks. If you have
questions, please call us at 501-682-5187 or 1-866-880-8444 (toll free).
/s/ Death & Permanent Total Disability Trust Fund
AFFIDAVIT
I, ________________________, do certify that I was a dependent of ____________________, deceased,
Dependent's Name
Claimant
and have instructed family members or the executor/-trix of my estate to promptly notify the Trust Fund upon
my death.
Beneficiary’s signature
State of
)
County of
)
Subscribed and sworn to before me this _______ day of _______________________, 2________.
My commission expires:
Notary Public
Ark. Code Ann. §11-9-1 06(a): “Any pers on or enti ty wh o willfu lly and knowingly makes any material false statement or rep resentation, who w illfully and knowin gly omits
or conceals any material information, or who willfully and knowingly employs any device, sch eme, or artifice for the purpose of: obtaining an y benefit or payment; defeating or
wron gfully increasing or wrongfully decreasing any claim for benefit or payment; or obtaining or avoiding workers’ compensation coverage or avoiding payment of the proper
insurance premium, or who aids and abets for any of said purposes, under this chapter shall be guilty of a Class D felony. Fifty percent (50% ) of any criminal fine imposed and
collected under ... this section shall be paid and allocated in accordance with applicable law to the Death and Permanent Total Disability Trust Fund administered by the Workers’
Com pens ation C omm ission .”
SF-6
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