AFFIDAVIT IN SUPPORT OF REDEMPTION (SETTLEMENT) AGREEMENT Michigan Department of Labor & Economic Growth Workers’ Compensation Agency/Board of Magistrates PO Box 30016, Lansing, MI 48909 ________________________________________ Plaintiff ______________________ County ____________________________________ Defendant I, _______________________________________________________, the plaintiff in this case against ____________________________________________________________, the defendant(s), affirm that the following are true and correct statements: 1. While employed by ________________________________________________, the defendant(s), I was injured on or about ________________________________. (Date) 2. I have been offered the sum of $ ___________________________________ to settle my workers’ compensation claim, both weekly and medical benefits and possible rehabilitation. 3. I understand that by accepting this amount of money I am waiving all workers’ compensation rights I may have against this (these) defendant(s) and its (their) workers’ compensation insurance carrier(s). 4. I have voluntarily entered into the redemption agreement. 5. If I have filed an Application for Mediation or Hearing under the Michigan Workers’ Disability Compensation Act, the application alleges a compensable condition. 6. My attorney, or the magistrate, has fully explained to me the rights that I have under the Workers’ Disability Compensation Act and I understand that this redemption agreement, if approved by the magistrate, will extinguish all of those rights. 7. I have fully disclosed to my attorney, or the magistrate, any other benefits that I am receiving or may be entitled to receive and it has been explained to me what effect, if any, the redemption agreement might have on those other benefits. Those other benefits are 8. I have fully disclosed to my attorney, or the magistrate, the nature and extent of the injuries and/or disabilities incurred by me during my employment with the defendant(s). Those injuries are: (Over) WC-119 (8/05) (Front) American LegalNet, Inc. www.FormsWorkflow.com 9. I have disclosed my age to my attorney or the magistrate and I have been advised of the possible life expectancy of a person my age. My age is __________. My life expectancy is _____________. 10. I do do not have health, disability, or other related insurance. The insurance coverage I have is: 11. My marital status is ________________________________. I have ____________ dependents. 12. I have advised my attorney or the magistrate whether, to my knowledge, any other person or entity has any claim on the proceeds of the redemption agreement. The person or entity having such a claim is: 13. My average monthly expenses are: 14. My intentions for the use of the monies received as a result of the redemption agreement are: 15. The amount of workers’ compensation benefits I have received from the defendant(s) or its (their) insurance carrier(s) as a result of my alleged injuries is: _________________. Plaintiff’s Signature Signed and sworn to before me on __________________ in __________________ County, Michigan. Date . My commission expires . Notary Public The Department of Labor & Economic Growth will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency. WC-119 (8/05) (Back) Authority: Workers’ Disability Compensation Act, 418.836 Completion: Mandatory Penalty: Redemption will not be heard American LegalNet, Inc. www.FormsWorkflow.com