BEFORE THE IOWA WORKERS COMPENSATION COMMISSIONER________________________________________________________________________ : : : Claimant, : : : File No. _____________vs. : : APPLICATION TO DEFER : : PAYMENT OF FILING FEES, Employer, : : FINANCIAL AFFIDAVIT AND ORDER :and : : : : : Insurance Carrier, : Defendants. : _________________________________________________________________________ I, the undersigned, hereby request the Iowa Workers Compensation Commissioner toaccept for filing my Original Notice and Petition without prepayment of filing fee(s). I herebystate that if I am unable to defer the filing fee(s) in this matter, I would be unable to maintainthis action, and there is no reasonable alternative means for procuring the filing fee(s). Iunderstand that if the Original Notice and Petition is accepted for filing without prepayment ofthe filing fee(s), provision for the payment of the filing(s) must be included in any settlementsubmitted to the Workers Compensation Commissioner for approval, or taxed as costs aspart of a hearing on my petition. In support of my request, I hereby submit the following affidavit under oath (attachadditional sheets if necessary). >>>> 2Current mailing address:_____________________________________________Current phone number:______________________________________________Age:________________ Marital status: Single______Married_______Divorced_______Widow(er)_______Name of spouse:____________________Live with spouse? Yes____No____If no, length of separation from spouse:_______________________________Number and ages of dependents:_______________________________________________________________INCOME: Your occupation:_______________________ Are you presently working? Yes____ No____ If yes: Present Employer:_____________________________ Address:______________________________________ Weekly take-home earnings: $______________ Weekly gross earnings: $______________ Earned income for past 12 months: $___________ If no: Are you currently receiving weekly workers compensation benefits of any kind? Yes____No____ If yes, amount: $_________ Total received in last 12 months: $___________________ Are you currently receiving any other kind of disability income, such as sick leave, social security disability, or private disability insurance payments? If so, state amount: $_________per________ Are you receiving child support for any dependents?______________ If so, how much? $______________per____________________.List all other sources and amounts of income, in your name, name of spouse or jointly sharedwith another, including spouses salary (net wages), pensions, bonds, stocks, securities,private business, farming, insurance, retirement benefits, social security benefits, lawsuits orsettlements, gifts or others:______________________________. Unemployment compensation, heating assistance, food stamps, ADC or welfare relief, inyour name, spouses name or jointly shared with another: $_________per __________List any anticipated tax refunds in the next 6 months and the amount thereof:_______Whether or not you are presently working, state your income from all sources for the past 12months: $______________________. 2>>>> 3ASSETS: Bank with:____________________________Address:____________________________ Balance personal bank accounts (checking and savings): $_____________ Balance accounts in name of spouse: $________________ Balance joint accounts with spouse: $_________________ Balance joint accounts with any other person: $_________ List the amount of cash currently in your possession or available to you, including cash onyour person, at your place of residence, in safety deposit boxes, or in any other location:$________________________________ Real Estate: Property 1: Type (residence, farm, etc): __________________ Address or location: __________________________ Market value: ________________________________ Insured value:________________________________ Insured with: _____________________________ Address:__________________________________ Tax value:___________________________________ When purchased: ____________________________ Purchase price: ______________________________ Present owners besides yourself: ___________ ____________________________________________ Amount of mortgages or liens on property: ______________________________ Is this a homestead? Yes ____ No ____ Property 2: Type (residence, farm, etc.): __________________ Address or location: _________________________ Market value: _______________________________ Insured value:_______________________________ Insured with:___________________________ Address:_______________________________ Tax Value:__________________________________ When purchased:____________________________ Purchase price:______________________________ Present owners besides yourself: _____________ ____________________________________________ Amount of mortgages or liens on property: __________________________________ Is this a homestead? Yes ____ No ____ If more than two properties are owned, list others on a separate sheet and attach tothis form. Is such a sheet attached? Yes_____ No____ 3>>>> 4Motor vehicles: Give make, year, present value, amount owing thereon, if any, and whetherregistered or titled in your name, name of spouse or jointly with another of all vehicles in which youhave an ownership interest: Vehicle 1: Description_______________________________ Value $____________ Emcumbrance: $_________________ Lienholder: _____________________ Address: _______________________ Vehicle 2: Description________________________________ Value $ ___________ Encumbrance $ __________________ Lienholder: ______________________ Address: ________________________Other assets in your name, in the name of your spouse, or jointly owned with someone else, includingfurniture, appliances, televisions, stereos, videotape equipment, photographic cameras, jewelry, furs,trust funds, notes, bonds, stocks, savings certificates, securities, cash value of life insurance,equipment or machines, boats, aircraft, motorcycles, campers or recreational vehicles, coin or stampor any other collections with a recognized market value, livestock, purebred animals, harvested orunharvested crops, etc. and value of each: ________________________________________________________________________________________________________________________________________________________________Are you a beneficia