Form SF-6 Rev. 1-1-2001 Autho rity: Ark. Code Ann. §11-9-527 ARKANSAS WORKERS' COMPENSATION COMMISSION SPECIAL FUNDS DIVISION 324 Spring Street, P. O. Box 950, Little Rock, AR 72203-0950 501-682-5187 / 1-866-880-8444 (Toll-free) SF-6 AFFIDAVIT FOR DEPENDENTS OTHER THAN SPOUSE OR CHILD (Parent, brother, sister, grandparent, grandchild) Date:_____________________ (Date Mailed) Re: ____________________________ 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 American LegalNet, Inc. www.FormsWorkFlow.com