Affidavit Of Employee In Application For Trust Fund Benefits Form. This is a Massachusetts form and can be use in Workers Comp.
Tags: Affidavit Of Employee In Application For Trust Fund Benefits, 170, Massachusetts Workers Comp,
COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar No. The Commonwealth of Massachusetts DIA USE ONLY Department of Industrial Accidents – :Department 170 JUDICIAL SUBPOENA Plaintiff(s) Workers’ Compensation Trust Fund -against: 600 Washington Street – 7th Floor, Boston, Massachusetts 02111 FORM 170 Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470 http://www.mass.gov/dia : : AFFIDAVIT OF EMPLOYEE IN APPLICATION Defendant(s) FOR TRUST FUND BENEFITS : ...................................................... I, _____________________________________, do swear and depose as follows: (Name of employee/claimant) 1. I reside at THE STATE OF NEW YORK THE PEOPLE OF ________________________________________________________. TO 2. Home telephone # _________________________________________________. On the date of my injury my employer was ______________________________. The address of my employer is ________________________________________. GREETINGS: My supervisor's name is _____________________________________________. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before 3. While , the Honorable working for my employer, I was injured on _________________________. at the Court (Date of Injury) located at County of in roomThe injury ,occurred at _______________________________________________. and at any recessed on the day of , 20 , at o'clock in the noon, (Address, city and town) or adjourned date, to testify and give evidence as a witness in this action on the part of the Witnesses to my injury were __________________________________________ (Name and address of witness) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to __________________________________________ the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a (Name and address of witness) result of your failure to comply. 4. I have been informed that my employer, at the time of my injury, did not carry workers' Witness, Honorable one of §25A). compensation insurance as required by Massachusetts law (M.G.L., c. 152, the Justices of the Court in County, day of , 20 5. I am now applying to the Workers' Compensation Trust Fund (WCTF) for appropriate benefits. 6. (Attorney must sign above and type name below) At the time of my injury, I was earning wages of $_________ per week from my employer by CASH - CHECK. (Circle one) Attorney(s) for SIGNED UNDER THE PAINS AND PENALTIES OF PERJURY THIS ____________ DAY OF_______________ 20___ (Date) (Month) (Year) Office and P.O. Address ______________________________________________ Signature of Employee/Claimant Telephone No.: Facsimile No.: 170 - November 2002 Form E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com