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Form 14-0075 - Application To Defer Payment Of Filing Fees, Financial Affidavit And Order Page 5

I, the undersigned, being duly sworn under oath, certify under penalty of perjury and

pursuant to the laws of the State of Iowa that the foregoing statements are true and correct to

the best of my knowledge, and are made in support of my request that my Original Notice

and Petition be filed without payment of a filing fee at the time of filing. I understand that a

knowingly false statement in this affidavit may constitute a fraudulent practice under Iowa

Code section 714.8(2) and may subject me to criminal penalties, including imprisonment, fine

or both. I also hereby authorize the Iowa Workers’ Compensation Commissioner or any of

the Commissioner’s designees to investigate any statements contained herein, and I hereby

waive any privilege and release any information to the Commissioner or the Commissioner’s

designees to facilitate an investigation of the truth of this affidavit. I further state that I am the

claimant in the above-entitled action, that I have read the above Application and understand

its contents, and that the statements it contains are true to the best of my knowledge.

______________________________________

Claimant

Subscribed and sworn to by ___________________________________ before me, a

Notary Public, this _____ day of ________________________________, ____.

______________________________________

Notary Public for the State of Iowa

Form 14-0075 - Application To Defer Payment Of Filing Fees, Financial Affidavit And Order Page 5