STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS OFFICE OF THE JUDGES OF COMPENSATION CLAIMS , ) (Employee) ) Claimant, ) ) ) OJCC Case No. vs. , ) (Employer) ) Date of Accident: ) Employer/Carrier/Servicing Agent ) ______________________________________) VERIFIED PETITION FOR RELIEF FROM PAYING COSTS OF PREPARATION OF THE RECORD STATE OF FLORIDA COUNTY OF BEFORE ME this day personally appeared ___________________ ____________________, who, being sworn, deposes and says that the following information is true and correct according to his/her best knowledge and belief: Pursuant to Sections 57.081(1) and 440.25(5), Florida Statutes, and Rule 9.180(g)(3), Florida Rules of Appellate Procedure, I, __________________________________(Appellants Name), hereby petition the judge of compensation claims for an order relieving me from paying the costs of preparing the record on appeal in this matter. In support of this petition, I state: 1. I am insolvent as defined in Section 440.02, Florida Statutes, because _____ I have ceased to pay my debts in the ordinary course of business and cannot pay my debts as they become due or _____ I have been adjudicated insolvent pursuant to the federal bankruptcy law. (check one) 2. I am unable to pay the costs of preparation of the record due to my insolvency. 3. I have not paid or promised to pay any remuneration to any person for services performed on my behalf in connection with this proceeding. 4. Attached is _____ a completed financial affidavit or _____ a certification completed by my attorney. (check one) [omit Paragraph 5 if Appellant is represented] 5. It is my opinion that the appeal was filed in good faith and the appellate court reasonably could find reversible error in American LegalNet, Inc. www.USCourtForms.com>>>> 2the record. My opinion is based upon the following specific legal and factual grounds [state with particularity]: Respectfully submitted, _______________________________ (Appellants Name) Sworn to and subscribed before me this _____ day of _______ ___________, 20__, by ___________________________(Name of Notary Public). ______________________________(Signature of Notary Public) Notary Public, State of Florida (Print, Type, or Stamp Commissioned Name of Notary Public) Personally Known _____OR Produced Identification _____ Type of Identification Produced ______________ CERTIFICATE OF SERVICE I certify that a true and correct copy of this Petition (with attachments) has been furnished this _____ day of ________ ________, 20__, to: 2 American LegalNet, Inc. www.USCourtForms.com>>>> 3 [parties/attorneys of record] [General Counsel of the Department of Insurance] [Clerk of the First District Court of Appeal] 3 American LegalNet, Inc. www.USCourtForms.com