FORM 136 The Commonwealth of Massachusetts Department of Industrial Accidents Department 136 Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111 - 1750 Info. Line (800) 323 - 3249 Inside Mass. / (857) 321 - 7470 Outside Mass. www.mass.gov/dia DIA Board # (If Known): AFFIDAVIT OF INDIGENCE AND REQUEST FOR WAIVER OF 247 11A(2) FEES d sheet may be filed in addition to, but not in place of, the answer. Information contained herein will only be made available to the parties and other persons as allowed under state or federal law. Give monthly figures. To convert weekly to monthly figures, multiply the weekly amount by 4.3. I. Social Security No. 1 : Date of Injury: Marital Status & No. of dependents: II. POVERTY AND ASSISTANCE QUALIFICATION [from SJC RULE 3:10 Section 1 (f)(i) and (ii)]: (a) I receive one of the following types of public assistance: Aid to Families with Dependent Children (AFDC), refugee resettlement benefits, Medicaid, or Supplemental Security Income (SSI) or; (b) I receive an annual income, after taxes, of 125% or less of the current poverty threshold referred to in M.G.L. c. 261 247 27A (b). 2 III. MONTHLY INCOME FROM ALL SOURCES: A. EMPLOYMENT OR SELF - EMPLOYMENT 1. GROSS: Self Spouse 3 a. Salary, Wages $ $ b. Tips, bonuses, self - employment income $ $ 2. TOTAL (a plus b) $ $ 3. DEDUCTIONS : c. Federal Income Tax $ $ d. State Income Tax $ $ e. FICA/state or other retirement $ $ f. Union dues $ $ g. Business expense, if self - employed $ $ 4. TOTAL DEDUCTIONS (c through g) $ $ 5. ADJUSTED INCOME ( 2 minus 4) $ $ ---------------------------------------------------------- 1 Disclosing Social Security Number is voluntary. It will assist in the processing of your request. 2 The 125% figures shall be available from the Department. The citation to 247 625 of the Economic Opportunity Act in M.G.L. c. 261, 247 27A, as recommended by St. 1980, c. 539, 247 5 has become 247 624. Pub. I. 88 - 425, title VI, 247 624 [42 U.S.C. 247 re is substantially the same poverty standard used by legal services programs funded by the Federal Legal Services Corporation. 42 U. S.C. 247 2996(a)(2)(A)&(B). 3 If there is a spouse, or person in substantially the same relationship, or parent (provided, in each instance, any such perso n lives in the same must list income, amounts contributed by each to REPRODUCE AS NEEDED. Page 1 of 2 - Please complete reverse side. Form 136 - Revised 7/2019 American LegalNet, Inc. www.FormsWorkFlow.com B. INCOME FROM OTHER SOURCES: Self Spouse h. $ $ i. Social Security $ $ j. Long - or Short - term Disability $ $ k. Welfare Benefits $ $ l. Unemployment Compensation $ $ m. Other sources (for example Rental Income, $ $ Pension Payments, Annuities, Alimony etc.) 6. TOTAL INCOME OTHER SOURCES (h - m) $ $ 7. TOTAL NET MONTHLY INCOME (5 PLUS 6) $ $ IV. BASIC LIVING COSTS (monthly): a. Rent $ $ b. Mortgage (Principal, Interest & Taxes) $ $ c. Food $ $ d. Clothing $ $ e. Utilities (Electricity/Gas) $ $ f. Heat $ $ g. Water/Sewer $ $ h. Telephone $ $ i. Transportation, e.g. Auto Loan, Auto Insurance $ $ j. Health Care/Health Insurance $ $ k. Support for Dependents $ $ l. Education Costs $ $ 8. TOTAL COSTS ( a through l ) $ $ 9. NET DISPOSABLE INCOME ( 7 minus 8 ) $ $ V. LIQUID ASSETS (Cash or Assets readily convertible to cash): a. Cash on hand $ $ b. Cash in bank, mutual or other fund/account $ $ Savings Acct. # Checking Acct. # c. Real Estate $ $ Location d. Stocks, bonds, etc. $ $ e. Motor Vehicle(s) Make Year Fair Market Value $ - Loan $ = Equity $ $ f. Other Liquid Assets $ $ TOTAL LIQUID ASSETS (a through f) $ $ I,, make this affidavit and request for a waiver and certify that I am unable to pay the filing fee mandated by c. 152 247 11A. I further certify that the information provided is true, complete, and accurate to the best of my ability, knowledge, and belief. I understand that some or all of this information is subject to, and must be accompanied by, verification. 4 Signed under the pains and penalties of perjury: DATE(mm/dd/yyyy): SIGNATURE: Other information relative to financial circumstances should be attached on separate sheets. 4 247 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com