DEPARTMENT OF LABOR & INDUSTRY WORKERS' COMPENSATION OFFICE OF ADJUDICATION CHILD SUPPORT LIEN AFFIDAVIT EMPLOYEE/DEPENDENT VS EMPLOYER WCAIS DISPUTE NUMBER DATE OF INJURY EMPLOYEE'S STATEMENT UNDER 23 Pa. C.S.A. SECTION 4308.1(F) 1. My full name is: _________________________________________________. 2. I am the employee or dependent in this workers' compensation proceeding. 3. My mailing address is: ____________________________________________. 4. My social security number is: _______________________________________. 5. My date of birth is: _______________________________________________. 6. Please initial one of the following statements: A. There is no outstanding child support order against me. ________ B. There is an outstanding child support order against me, and all payments are current. ________ C. There is an outstanding child support order against me, and payments are in arrears. ________ I verify that the information on and provided pursuant to this form is true and correct. I understand that false statements made on or pursuant to this form are punishable under 18 Pa.C.S.A.§ 4904 (relating to unsworn falsifications to authorities), and that this statement is made subject to the penalties of 18 Pa.C.S. § 4904. Dated: __________________ ________________________ EMPLOYEE/DEPENDENT ________________________ WITNESS NOTE: This statement must be accompanied by written documentation of arrears from the Pennsylvania Child Support Enforcement System website, or if no arrears exist, written documentation from the website indicating no arrears. Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-504 01-15 American LegalNet, Inc. www.FormsWorkFlow.com