Form 14-0075 - Application To Defer Payment Of Filing Fees, Financial Affidavit And Order

ADVERTISEMENT

BEFORE THE IOWA WORKERS’ COMPENSATION COMMISSIONER
________________________________________________________________________
:
:
:
Claimant,
:
:
:
File No. _____________
vs.
:
:
APPLICATION TO DEFER
:
:
PAYMENT OF FILING FEES,
Employer,
:
:
FINANCIAL AFFIDAVIT AND ORDER
:
and
:
:
:
:
:
Insurance Carrier,
:
Defendants.
:
_________________________________________________________________________
I, the undersigned, hereby request the Iowa Workers’ Compensation Commissioner to
accept for filing my Original Notice and Petition without prepayment of filing fee(s). I hereby
state that if I am unable to defer the filing fee(s) in this matter, I would be unable to maintain
this action, and there is no reasonable alternative means for procuring the filing fee(s). I
understand that if the Original Notice and Petition is accepted for filing without prepayment of
the filing fee(s), provision for the payment of the filing(s) must be included in any settlement
submitted to the Workers’ Compensation Commissioner for approval, or taxed as costs as
part of a hearing on my petition.
In support of my request, I hereby submit the following affidavit under oath (attach
additional sheets if necessary).

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 6