COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS' COMPENSATION 633 17th ST., SUITE 400 DENVER, CO 80202-3626 APPLICATION FOR INDIGENT DETERMINATION Request For Hearing Transcript Pursuant to C.R.S. Section 8-43-213 Claimant ______________________________________ Employer _____________________________________ Insurance carrier _______________________________ Household status of claimant: Single _______ Married _________ Divorced ________ W.C. number ___________________________________ Social security number ___________________________ Carrier number _________________________________ Number of dependents: Spouse ________ Children _______ Other ________ Ages of children: Separated _______ Bank accounts or other financial accounts: Checking Savings Other At ____________________________________________________ At ____________________________________________________ At ____________________________________________________ Account balance: $ ___________________________ $ ___________________________ $ ___________________________ $ ___________________________ Amount of cash on hand............................................................................................... Value of property and real estate owned: $ ______________ Vehicles owned: Year ______ Year ______ Make ________________ Make ________________ Value $ __________ Value $ __________ Gross monthly income of all household members: Earnings - claimant Earnings - spouse Earnings - other members $ ______________________ $_______________________ $ ______________________ Monthly expenses of household: Rent/House payment Utilities Food Clothing $_______________________ $_______________________ $_______________________ $_______________________ List other sources of income for household members. Include income such as AFDC, unemployment, welfare, social security, retirement pension, etc.: $ ______________________ $_______________________ $_______________________ $_______________________ Total household income: $_______________________ Alimony/Child support Medical bills Installment payments Other Total monthly expenses: $ $_______________________ $_______________________ $_______________________ $ ______________________ WC35 Rev 01/06 Page 1 of 2 (See other side) American LegalNet, Inc. www.FormsWorkFlow.com If further information or clarification is needed, it may be necessary for the Division of Workers = Compensation to contact the claimant, in writing. Please provide the claimant's current address below: Street/PO Box City, State, Zip If claimant is represented by an attorney, please provide name and address of attorney below: Attorney name Street/PO Box City, State, Zip Please note: A copy of this application will be sent to the insurance company, self-insured employer or uninsured employer and all attorneys. The Director, in considering this request, may use a standard of indigency accepted by the courts of the State of Colorado as an initial guideline. Please see the Supreme Court Directive on the subject of indigency and court-appointed attorneys. A dispute between the parties regarding this application may be referred for hearing before an Administrative Law Judge. I certify the information contained in this application is true and correct. Claimant signature State of Colorado County of Sworn to before me and subscribed in my presence this Notary public SEAL Address day of _____________ , _____. My commission expires If, for the purpose of obtaining any order, benefit, award,compensation, or payment under the provisions of articles 40 to 47 of [title 8], either for self-gain or the benefit of any other person, anyone willfully makes a for false statement or representation material to the claim, such person commits a class 5 felony and shall be punished as provided in Section 18-1 .3-401, C.R.S., and shall forfeit all right to compensation under said articles upon conviction of such offense. (Section 8-43-402, C.R.S.) WC35 Rev 01/06 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com