FORM 112A The Commonwealth of Massachusetts Department of Industrial Accidents ­ Department 112A 1 Congress Street , Suite 100, Boston, Massachusetts 02114-2017 Info. Line 800-323-3249 ext. 7470 in Mass. Outside Mass. - 617-727-4900 ext. 7470 http://www.mass.gov/dia DIA Use Only AFFIDAVIT IN SUPPORT OF REQUEST FOR WAIVER OF FILING FEE UNDER SEC. 11C Please provide DIA Board Number: ___________________________ Pursuant to General Laws c. 152, Sec. 11C, the applicant, ____________________________________ (Print Name of Applicant) swears (or affirms) as follows: 1. Applicant is indigent in that he/she is a person unable to pay the filling fee mandated by Sec. 11C, or is unable to do so without depriving himself or his dependents of the necessities of life, including food, shelter and clothing. In support of this affidavit, the applicant submits the following information: (a) (b) (c) (d) (e) (f) (g) (h) Address of Applicant: ____________________________________________________ Date of Birth: ___________________________________________________________ Highest grade attended in school: ___________________________________________ Special Training: ________________________________________________________ List any physical or mental disabilities: ______________________________________ Marital status: __________________________________________________________ Number of dependents (if applicable): _______________________________________ and ages of dependents: ________________________________________________ Income, expense, asset & liability information: Gross income from all sources (check one): $____________________ per _________ week/_________ month/________ year. If now working, list your occupation: and the name of your employer: _______________________________________________________ _________________________________________________________________________________ Source(s) of income, per _________ week/_________ month/________ year if not from employment: _____________ (check one) Workers' Compensation Benefits Social Security Disability $______________ $______________ Pension Other $______________ $______________ 2. Long Term Disability $______________ Other $______________ If spouse of applicant is employed, list occupation and name and address of his/her employer: __________________________________________________________________________________ Reproduce as needed. (OVER) Form 112A - Revised 7/2013 American LegalNet, Inc. www.FormsWorkFlow.com Applicant and spouse's gross annual income for the preceding year: $_____________________________ Deductions Federal Tax $_______________ State Tax $_______________ Social Security (FICA) $_______________ Other $_______________ Net Income (Specify whether monthly or weekly): $___________________ per _________________ Expenses (Specify whether monthly or weekly): Rent $_______________ Food $_______________ Clothing $_______________ Utilities $_______________ Other Expenses $_______________ TOTAL $_______________ Assets: Own car? ________ Year & Make _________________ Market Value $____________ Loan Amount $______________ Balance Due $____________ Monthly Payment $______________ Bank Accounts (number of and balance in each) _________________________________ ________________________________________________________________________ Real Property? ____________________________________ (Identify Type) Market Value $____________ Loan Amount $______________ Balance Due $____________ Monthly Payment $______________ Liabilities: __________________________________________________________ __________________________________________________________ __________________________________________________________ (i) Other facts which may be relevant to applicant's ability to pay the filing fee? ________________________________________________________________ ________________________________________________________________ SIGNED UNDER THE PAINS AND PENALTIES OF PERJURY: Signature of Applicant: ___________________________________________________ Type or Print Name of Applicant: ___________________________________________ ALL INFORMATION CONTAINED HEREIN IS CONFIDENTIAL. IT SHALL NOT BE DISCLOSED TO ANY PARTY OTHER THAN AUTHORIZED REVIEWING BOARD PERSONNEL. American LegalNet, Inc. www.FormsWorkFlow.com