Guardianship Affidavit Court-Appointed Non-Minor {SF-2}

Form SF-2 Rev. 1-1-2001 Autho rity: Ark. C ode Ann. §§ 11-9-527,-801 ARKANSAS WORKERS' COMPENSATION COMMISSION SPECIAL FUNDS DIVISION 324 Spring Street, P. O. Box 950, Little Rock, AR 72203-0950 501-682-5187 / 1-866-880-8444 (Toll-free) SF-2 GUARDIANSHIP AFFIDAVIT (Court-Appointed, Non-Minor) Date:_________________ (Date Mailed) Re: ______________________ (Claimant - AWCC File No.) ________________________ Name ________________________ Address ________________________ CERTIFIED MAIL Workers' compensation benefits are being paid to you in your capacity as court-appointed guardian of the estate of __________________________(the adult "ward"). You will receive those benefits until termination of your duties as the guardian, the death of the ward, or upon termination of the ward's eligibility. Please complete, sign, and have notarized the following Affidavit. This form must be returned to our office within the next thirty (30) calendar days. Failure to do so will result in a suspension of benefits. If you have any questions, please call 501-682-5187 or (toll-free) 1-866-880-8444. /s/ Death and Permanent Total Disability Trust Fund AFFIDAVIT I, _____________________________________, do hereby certify that I have been duly court-appointed and remain the guardian of the estate of ("ward"). I certify that I will promptly notify the Trust Fund of any modification or termination of this guardianship, or the ward's death. State of ____________________ ) County of __________________ ) Signature SUBSCRIBED AND SWORN TO before me on the ____ day of ____________________, 2_______. Notary Public My Commission Expires: Ark. Code Ann. §11-9-1 06(a): " Any person or entity wh o willfully and knowingly makes any material false statement or representation, who willfully and know ingly omits or conceals an y material information, or who willfully and knowingly employs any device, scheme, or artifice for the purpose of: obtaining any ben efit or payment; defeating or wrongfully increasing or wrongfully decreasing any claim for ben efit or payment; or obtaining or avoidin g workers' compe nsation coverage or avoiding paymen t of the proper insuran ce premiu m, or who aid s and abe ts for any of said purposes, under this chapter shall be guilty of a Class D felony. Fifty percent (50%) of any criminal fine imposed and collected under .... this section shall be paid and allocated in accordance with applicable law to the Death and American LegalNet, Inc. www.FormsWorkFlow.com SF-2