Form SF-3 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-3 POWER OF ATTORNEY NOTICE & AFFIDAVIT Date:_________________ (Date Mailed) Re: ______________________ (Claimant - AWCC File No.) ________________________ Name ________________________ Address ________________________ CERTIFIED MAIL Workers' compensation benefits are paid for the use and benefit of . He/she will continue to receive these benefits until death or termination of eligibility. Since you have the power of attorney for this beneficiary, we ask you to complete, sign, notarize and return to this office this Affidavit. This form must be returned to us within thirty (30) calendar days. Failure to do so will result in a suspension of benefits. If you have questions, please call us at 501-682-5187 or (toll-free) 1-866-880-8444. /s/ Death & Permanent Total Disability Trust Fund AFFIDAVIT I, ________________________, do certify that I have legal power of attorney, executed by the beneficiary _____________________________, and that I will promptly notify the Trust Fund of any modification or termination of this power of attorney, or in the event of death of the named beneficiary, or if the beneficiary is no longer eligible for benefits. Signature of Power of Attorney County of State of ) ) ,2 . Subscribed and sworn to before me this ________ day of 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 makes any m aterial false statement or representation , who willfully and knowingly 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 wrongfully increasing or wrongfully decreasing any claim for benefit or payment; or obtainin g or avoiding workers' com pensation 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 u nde r .... th is se ction shall be paid and allocated in accordance with applicable law to the Death and Permanent Total Disability Trust Fund administered by the Worke rs' Com pens ation C omm ission ." SF-3 American LegalNet, Inc. www.FormsWorkFlow.com