ARKANSAS WORKERS’ COMPENSATION COMMISSION Form SF-5 Rev. 1-1-2001 SPECIAL FUNDS DIVISION Autho rity: Ark. Code Ann. §11-9-801 SF-5 501 Woodlane, Suite 101, Little Rock, AR 72201 501-682-5187 / 1-866-880-8444 (Toll-free) GUARDIAN’S AFFIDAVIT - DEPENDENT CHILD(REN) Re: _____________________, Deceased AWCC File No. _____________ Claimant AWCC File No. (Please read the cover letter from the Death & Permanent Total Disability Trust Fund that came with this Affidavit before completing the Affidavit.) AFFIDAVIT I, ____________________________________________ , hereby certify that I am the lawful legal guardian Guardian's Name of the estate(s) of the dependent(s) named below of _______________________________________(deceased), that Claimant the information given about the child(ren) is correct, and I will promptly notify the Trust Fund of any change in my court-appointed guardianship or physical custody of any named dependents. (Check if used: G Additional dependent children are listed on the back of this sheet.) Dependent (name) is currently living in the household of: Name of person or agency child currently lives with That person’s relationship to child Address Guardian’s home telephone City Guardian’s work telephone, if any Name of school this child currently attends, if any State ZIP Name and place of work, if any School telephone number Current grade level Guardian’s signature State County ) ) 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 know ingly mak es an y mat erial fa lse st atem ent o r representat ion, who willfully and know ingly omits or con ceals any m ateri al informa tion, or who w illfully an d kn owin gly em ploys any d evice, schem e, or artifice for th e pu rpos e of: obtaining any benefit or payment; defeating or wron gfully increasing or wrongfully decreasing any claim for benefit or payment; or obtaining or avoiding workers’ compe nsation coverage or avoiding paymen t of the proper insuran ce premiu m, or who aid s and abe ts 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 Perm anen t Total Di sability Trust Fu nd ad ministered by the W orkers’ C omp ensat ion Comm ission .” SF-5 American LegalNet, Inc. www.FormsWorkflow.com AW CC FO RM SF-5 GUARDIAN’S AFFIDAVIT DEPENDENT CH ILDREN - CONTINUATION SHEET 2. Dependent (name) is currently living in the ho useho ld of: Name o f perso n or agency child currently lives with Add ress Guardian’s home telephone That person’s re lationship to ch ild City W ork telephone, if any Name o f school this child currently attends, if any Add ress That person ’s relationship to child City W ork telephone, if any Name o f school this child currently attends, if any State ZIP Name and place of work, if any School telephone number 4. Dependent (name) Current grade level is currently living in the ho useho ld of: Name o f perso n or agency child currently lives with Add ress That person ’s relationship to child City W ork telephone, if any Name o f schoo l this child currently attends, if any State ZIP Name and place of work, if any School telephone number 5. Dependent (name) Current grade level is currently living in the ho useho ld of: Name o f perso n or agency child currently lives with Add ress Guardian’s home telephone Current grade level is currently living in the ho useho ld of: Name o f perso n or agency child currently lives with Guardian’s home telephone ZIP Name and place of work, if any School telephone number 3. Dependent (name) Guardian’s home telephone State That person ’s relationship to child City W ork telephone, if any Name o f school this child currently attends, if any State ZIP Name and place of work, if any School telephone number Current grade level SF-5 American LegalNet, Inc. www.FormsWorkflow.com