MN AS01 (6/18) (over) Office of Administrative Hearings PO Box 64620 St. Paul, MN 55164-0(651)361-7900 Affidavit of Significant Financial Hardship PRINT IN INK or TYPE ENTER DATES in MM/DD/YYYY FORMAT DO NOT USE THIS SPACE WID or SSN DATE(S) OF CLAIMED INJURY EMPLOYEE VS. EMPLOYER(S) AND INSURER(S) AND quickly as possible). The request must include a sworn affidavit attesting to the facts that establish financial hardship above Private or confidential data you supply on this form, and in communications or proceedings that occ ur because you file this form, will be used to the office of administrative hearings (OAH) and the department of labor and industry staff who have authorized access to the dat a, and may be used for state investigations and statistics. You may refuse to supply the data, but if you refuse your claim may be delayed or denied, or the form may be returned to you. The data will be made part of the may be supplied to: anyone who has access to the file or the data by authorization or court order; the employer re insurance association. The employee above named, for his/her request for an expedited hearing, alleges the following facts: 1. That he/she is presently: Unemployed Employed and the present income is per month (include all sources). 2. That employee presently owes the following debts: (list each debt separately) Owed To Amount 3. Living Expense Amount Weekly Monthly Living Expense Amount Weekly Monthly American LegalNet, Inc. www.FormsWorkFlow.com 4. That employee claims the following dependents: (attach additional sheet if necessary) Name Age Relationship 5. That there is is not spousal or other family income, other periodic benefit, or insurance payments. List the source and amount of such income. Income Source Amount Weekly Monthly 6. That should this request not be granted, foreclosure of homestead property, eviction, or repossession of necessary personal p roperty is imminent. Describe. 7. That the following exceptional circumstances exist and should be considered in the granting of this request: If an interpreter is requested for a hearing or conference, specify the language/dialect: If a reasonable accommodation of disability is requested for a hearing or conference, describe: STATE OF MINNESOTA } } ss. AFFIDAVIT OF SIGNIFICANT COUNTY OF } FINANCIAL HARDSHIP I, , being first duly sworn, depose and state that the above information is a truthful representation of my financial status as of this day of . Subscribed and sworn to before me this day of Signature Notary Public My Commission expires INSTRUCTIONS 1. When completing the Affidavit of Significant Financial Hardship, make certain to sign it in the presence of a notary public. 2. This material can be made available in different forms, such as large print, Braille or audio. To request, call (651) 284-5032 or 1-800-342-5354. ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3. American LegalNet, Inc. www.FormsWorkFlow.com