Affidavit In Support Of Employees Request For Speedy Conference Because Of Hardship {132}

FORM 132 The Commonwealth of Massachusetts Department of Industrial Accidents Department 132 Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111 - 1750 Info. Line (800) 323 - 3249 Inside Mass. / (857) 321 - 7470 Outside Mass. www.mass.gov/dia DIA Board # (If Known): REQUEST FOR SPEEDY CONFERENCE BECAUSE OF HARDSHIP DIA Board #: DIA Region: Date of Injury: Employer: A. Names and ages of minor children living with you: 1. ; 2. ; 3. ; 4. ; 5. ; 6. ; B. Names of persons over 18 who live with you and who are currently financially dependent on you; 1. ; 2. ; 3. ; C. Check all applicable boxes - I live with my : Spouse Parents Other 3. CURRENT GROSS WEEKLY INCOME FROM ALL SOURCES: You Spouse Other Source A. $ $ $ B. Unemployment Insurance $ $ $ C. Private Disability Insurance $ $ $ D. Public Assistance (Welfare, AFDC Payments etc.) $ $ $ E. Food Stamps (Gross Value of Weekly Allotment) $ $ $ F. Social Security $ $ $ G. Dividends $ $ $ H. Income from Trusts and Annuities $ $ $ I. Pensions and Retirement Funds $ $ $ J. Alimony and/or Child Support $ $ $ K. Contribution/Income from other sources $ $ $ L. All other income not set forth above $ $ $ M. TOTAL GROSS WEEKLY INCOME (add A thru L) $ $ $ *Disclosing Social Security Number is voluntary. It will assist in the processing of your request. REPRODUCE AS NEEDED. Page 1 of 2 - Please complete reverse side. Form 132 - Revised 7/2019 American LegalNet, Inc. www.FormsWorkFlow.com 4. CURRENT WEEKLY EXPENSES: A. Rent or Mortgage (Principal, Interest & Taxes) $ B. $ C. Maintenance and Repair of Dwelling $ D. Heat $ E. Electricity $ F. Telephone $ G. Water/Sewer $ H. Food $ I. Clothing $ J. Life and Health Insurance Premiums $ K. Court Judgment on which you pay regular amount $ L. Auto Insurance $ M. Auto Payment $ N. Child Care $ O. Credit Cards $ P. Other (explain) $ TOTAL WEEKLY EXPENSES $ 5. PERSONAL PROPERTY/LIQUID ASSETS A. IRA, Keogh $ B. Stocks, Bonds $ C. Life Insurance: Present Cash Value $ D. $ E. Automobiles 1. Fair Market Value $ - Loan $ = Equity $ 2. Fair Market Value $ - Loan $ = Equity $ F. Other Personal Property $ TOTAL PERSONAL PROPERTY/LIQUID ASSETS $ I HEREBY CERTIFY UNDER THE PAINS AND PENALTIES OF PERJURY THAT THE ABOVE INFORMATION IS TRUE AND COMPLETE. Signed: Date (mm/dd/yyyy): Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com