MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS TORT VICTIMS' COMPENSATION QUESTIONS AND AFFIDAVIT FOR CLAIMANT REGARDING WAIVER OF FINAL JUDGMENT AND REQUIREMENT ­ AFFIDAVIT FORM C 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) , state that I have not obtained a final judgment against the tortfeasor regarding the tort forming the basis of my claim against the Missouri Tort Victims' Compensation Fund. I understand that such a final judgment is required in order to be eligible to receive compensation, unless a waiver is granted by the Division of Workers' Compensation. I understand that such waiver can only be granted if certain conditions are met. Therefore, in order to obtain such a waiver, and as part of my claim against the Missouri Tort Victims' Compensation Fund, I hereby answer the following questions truly, accurately and completely. 1. Has the tortfeasor declared bankruptcy? a. Tortfeasor's name; b. District court in which bankruptcy proceedings took place; c. Date and type of discharge; and d. Whether you were named as a creditor in the proceedings. You may attach copies of documents to explain or supplement your answers. Yes No If "Yes," state: WCT-4 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com 2. Have you been unable to identify the tortfeasor? Yes No If "Yes," state in detail the facts and circumstances explaining why you have been unable to identify the tortfeasor. If there is a document (e.g., police report, private investigator's report) detailing the facts and circumstances, attach a copy. 3. Have you been unable to obtain service of process on the tortfeasor after making a good faith effort to do so? Yes No If "Yes," state in detail the efforts you have made (or which have been made on your behalf) to obtain service of process on the tortfeasor. Attach all court documents and any other documents evidencing the efforts to obtain service of process. WCT-4-2 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com 4. Has the claim against the tortfeasor been settled for the insurance policy limits available to cover the liability of such tortfeasor, but such policy limits are inadequate in light of your injuries? Yes No If yes, you must also complete Form WCT-2, Questions and Affidavit for Claimant Regarding Benefit Sources and Payments ­ Affidavit Form A. 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-4-3 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com