Les Form Afsu-10 - Financial Affidavit - State Of Florida Department Of Labor And Employment Security

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STATE OF FLORIDA
DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY
OFFICE OF THE JUDGE OF COMPENSATION CLAIMS
DISTRICT _______________
STATE OF FLORIDA, DEPARTMENT OF
ATTORNEY FOR STATE:
LABOR AND EMPLOYMENT SECURITY,
DIVISION OF WORKERS' COMPENSATION
CLAIMANT:
CLAIMANT'S ATTORNEY:
EMPLOYER:
ATTORNEY FOR EMPLOYER/CARRIER:
CARRIER (SERVICING AGENT)
CLAIM NUMBER:
DATE OF ACCIDENT:
LES Form AFSU-10 (06/29/94)
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