MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS TORT VICTIMS' COMPENSATION QUESTIONS AND AFFIDAVIT FOR CLAIMANT REGARDING LOST INCOME ­ AFFIDAVIT FORM B File No: Claimant's Name: 3315 West Truman Blvd., P.O. Box 58 Jefferson City, MO 65102-0058 573-751-4231 www.labor.mo.gov/DWC (Please type or print your answers. You may use additional sheets if necessary.) I, (name of undersigned claimant) , as part of my claim against the Missouri Tort Victims' Compensation Fund, hereby answer the following questions truly, accurately and completely. 1. Are you claiming a past loss of wages, salary, or income from one or more employers (not including selfemployment, employment as an independent contractor, or from a business or venture in which you have an ownership interest)? Yes No If "Yes," for each employer, state: a. Name, address and telephone number of employer; b. Inclusive dates of income loss; c. Medical and/or other reasons for inability to work; and d. Amount of wages, salary or income lost, and how calculated. Provide copies of all documents supporting your answers. Failure to provide documentation may delay the evaluation of your claim. WCT-3 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com 2. Are you claiming a past loss of income from self-employment, employment as an independent contractor, or from a business or venture in which you have an ownership interest? Yes No If "Yes," state: a. Nature of self-employment, or other business or venture; b. Trade name ("d/b/a"), if applicable; c. Share of your ownership interest; d. Names of other owners and their respective ownership shares; e. Inclusive dates of income loss; f. Medical and/or other reasons for income loss; and g. Amount of income lost, and how calculated. Provide copies of all documents supporting your answers. Failure to provide documentation may delay the evaluation of your claim. 3. Are you claiming a continuing or future loss of income? a. Anticipated duration of such loss of income; Yes No If "Yes," state: b. Medical and/or other reasons for such anticipated loss of income; and c. Amount of such anticipated loss of income, and how calculated. Provide copies of all documents supporting your answers. Failure to provide documentation may delay the evaluation of your claim. WCT-3-2 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com 4. Are you claiming a future loss of earning capacity? Yes No If "Yes," state: a. Medical and/or other reasons for such anticipated future loss of earning capacity; and b. Dollar amount claimed for such loss of earning capacity and how calculated. Provide copies of all documents supporting your answers. Failure to provide documentation may delay the evaluation of your claim. Oath or affirmation. I, (print name) , under oath or affirmation, state that the foregoing answers, statements and representations are true and correct to my best knowledge and belief, subject to the penalties of making a false affidavit or declaration. Signature WCT-3-3 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com