WC-226a PETITION FOR APPOINTMENT OF TEMPORARY CONSERVATOR OF MINOR(S) GEORGIA STATE BOARD OF WORKERS' COMPENSATION PETITION FOR APPOINTMENT OF TEMPORARY CONSERVATOR OF MINOR(S) Board Claim No. Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury EMPLOYEE IDENTIFYING INFORMATION Address County of Injury City State Zip Code Employee E-mail PETITIONER IDENTIFYING INFORMATION Last Name First Name Address M.I. Date of Birth City State Zip Code Social Security Number County of Residence Petitioner E-mail Re: 1. , Minor(s) Pursuant to the provisions of O.C.G.A. 34-9-226 (name of petitioner) hereby petitions the State Board of Workers’ Compensation to appoint a temporary conservator for the above-referenced minor(s) to bring or defend an action under this chapter, to receive and administer weekly income benefits on behalf of and for the benefit of said minor(s) for a period not to exceed 52 weeks, and/or to compromise and terminate any claim and receive any sum in settlement for the benefit of and use of said minor(s) where the net settlement amount is less than $100,000. 2. The minor(s) date(s) of birth is (are) 3. Petitioner is the (state the relationship between petitioner and minor(s) and attach supporting documentation such as marriage or birth certificates, orders of custody or support, etc.) Yes No 4. The minor child or children reside with the petitioner: 5. The Board should exercise its discretion and allow petitioner as natural conservator to receive and administer workers’ compensation benefits for said minor(s). 6. Petitioner will hold and use such property for the benefit of the minor(s) and shall be legally accountable to the minor(s) for the proper handling of such property. Name Telephone Number ATTORNEY (If applicable) Address GA Bar Number City State Zip Code IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS’ COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. 34-9-18 AND 34-9-19). WC-226a REVISION . 07/2012 226a 1 OF 3 PETITION FOR APPOINTMENT OF TEMPORARY CONSERVATOR OF MINOR(S) American LegalNet, Inc. www.FormsWorkFlow.com WC-226a PETITION FOR APPOINTMENT OF TEMPORARY CONSERVATOR OF MINOR(S) GEORGIA STATE BOARD OF WORKERS' COMPENSATION VERIFICATION Personally appeared before me the undersigned petitioner who on this oath states that the facts set forth in the foregoing petition are true. Petitioner Name Address Telephone Number City Sworn to and subscribed before me this State day of Zip Code , (day) (month) . (year) Notary Public CERTIFICATE OF SERVICE I hereby certify that I have today sent a copy of this form to all parties named above and to the State Board of Workers’ Compensation, 270 Peachtree Street, N.W., Atlanta, GA 30303-1299. Signature Date IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS’ COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. 34-9-18 AND 34-9-19). WC-226a REVISION . 07/2012 226a 2 OF 3 PETITION FOR APPOINTMENT OF TEMPORARY CONSERVATOR OF MINOR(S) American LegalNet, Inc. www.FormsWorkFlow.com WC-226a PETITION FOR APPOINTMENT OF TEMPORARY CONSERVATOR OF MINOR(S) GEORGIA STATE BOARD OF WORKERS' COMPENSATION CONFIDENTIAL Name Claim Number EMPLOYEE / CLAIMANT , Minor(s), Petition for Appointment of Temporary Conservator of Minor(s). CONSENT FORM I hereby authorize the State Board of Workers’ Compensation to receive any criminal history record information pertaining to me which may be in the files of any state or local criminal justice agency in Georgia. I have attached a copy of a criminal history record check for each jurisdiction, other than Georgia, where I have resided at any time during the five year period immediately prior to the date of this petition. I have lived in the following states other than Georgia: State Period I have never been arrested or convicted of any crime in Georgia or any other state except as follows: Date Crime Disposition Full Name State Signature of Petitioner Birthdate Social Security Number Address Sex Race City Sworn to and subscribed before me this day of State , (day) (month) Zip Code . (year) Notary Public IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS’ COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. 34-9-18 AND 34-9-19). WC-226a REVISION . 07/2012 226a 3 OF 3 PETITION FOR APPOINTMENT OF TEMPORARY CONSERVATOR OF MINOR(S) American LegalNet, Inc. www.FormsWorkFlow.com