ARKANSAS WORKERS’ COMPENSATION COMMISSION Form SF-4 Rev. 1-1-2001 SPECIAL FUNDS DIVISION Autho rity: Ark. Code Ann. §11-9-527 501 Woodlane, Suite 101, Little Rock, AR 72201 501-682-5187 / 1-866-880-8444 (Toll-free) SF-4 SURVIVING SPOUSE NOTICE & AFFIDAVIT Date:_____________________ Re: ____________________________ (Date Mailed) Claimant - AWCC File No. _________________________ Name _________________________ Address _________________________ CERTIFIED MAIL You are currently receiving compensation benefits under the provisions of the Arkansas workers' compensation law because of the death of your spouse. Your benefits continue until your death or remarriage. The law states you are entitled to a lump-sum payment upon your remarriage. Please complete, sign, and have notarized the following affidavit. This form must be returned to our office within the next thirty (30) calendar days. Failure to do so will result in a suspension of your benefits. If you have questions, please call us at 501-682-5187 or (toll-free)1-866-880-8444. /s/ Death and Permanent Total Disability Trust Fund AFFIDAVIT I, ________________________________ , surviving spouse of ___________________________, deceased, Name Claimant do hereby certify and affirm that I have not remarried since the death of my named spouse and to the accuracy of the following information: My place of employment: ____________________________________________________________________ Work telephone:____________________________ Home/message telephone: _________________________ State of ____________________ ) _____________________________________ Signature County of __________________ ) Subscribed & sworn to before me, a Notary Public, on this the ____ day of ____________________, 2_______. My Commission Expires: __________________________________________ Notary Public Ark. Code Ann. §11-9-106(a): “Any person or entity who willfully and knowingly makes any material false statement or representation, who willfully and knowingly omits or conceals any material information, or who willfully and knowingly employs any device, scheme, or artifice for the purpose of: obtaining any benefit or payment; defeating or wrongfully 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’ Compensation Commission.” SF-4 American LegalNet, Inc. www.FormsWorkflow.com