South Carolina Workers' Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 803-737-5675 Claimant's Name: Address: City: Home Phone: Preparer's Name: ( ) State: Work Phone: ( Zip: ) SSN: Employer's Name: Address: City: Carrier: Preparer's Phone #: REQUEST TO WAIVE APPEAL FILING FEE 1. Are you presently employed? a. Yes No ( ) WCC File #: Carrier File #: Carrier Code #: Employer FEIN #: State: Zip: - If yes, state the name and address of your employer and wages below. b. If no, where did you last work, when did you stop working, and what were your wages? c. Is your spouse employed? Yes No If yes, where? What are your spouse's wages? $ d. What is the total income of all working members of your household? 2. How many people are dependent on you for their support (include children and relatives)? How much do you spend weekly for their support? $ 3. List any money you have received in the past year other than that listed above and state from what source that money came (gift, inheritance, insurance, 4. Do you have a checking or savings account? If yes, what is the balance in each account? 5. Do you rent or own your home? 6. Do you own a car? Yes Rent No Yes No Checking: $ Rent or mortgage payment: Payments: Savings: $ $ $ Own 7. List the names of your creditors and amount of debt. To the best of my knowledge, the information above is true and accurate. I have made no attempt to misrepresent my financial condition. I request that the filing fee be waived. Signature For official use only. Fee Waived Waiver Rejected Other Disposition Date Chair, S.C. Workers' Compensation Commission File this form with a Form 30, Application for Commission Review. Refer to R.67-701 through R.67-711 for additional information. File this form with a Form 50, 52, 54, Requests for Motions, Consents and Settlements. Refer to R.67-207, R.67-208, R.67-215, R.67-803 and R.67-805. WCC Form # 32 Rev. 7/03 32 REQUEST TO WAIVE APPEAL FILING FEE American LegalNet, Inc. www.FormsWorkFlow.com