STATE OF FLORIDA  DIVISION OF ADMINISTRATIVE HEARINGS  OFFICE OF THE JUDGES OF COMPENSATION CLAIMS  , ) (Employee) ) Claimant, ) ) vs. ) OJCC Case No. ) , ) Date of Accident: (Employer) ) Employer/Carrier/Servicing Agent ) ______________________________________)  VERIFIED PETITION FOR RELIEF FROM PAYING FILING FEE 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)(2), Florida Rules of Appellate Procedure, I, __________________________________(Appellants Name), hereby petition the judge of compensation claims for an order relieving me from paying the filing fee 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 filing fee 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. American LegalNet, Inc. www.USCourtForms.com>>>> 2 4. Attached is _____ a completed financial affidavit or _____ a certification completed by my attorney. (check one) _______________________________ (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: [parties/attorneys of record] 2 American LegalNet, Inc. www.USCourtForms.com>>>> 3 [General Counsel of the Department of Insurance] [Clerk of the First District Court of Appeal] 3 American LegalNet, Inc. www.USCourtForms.com