Lien Disclosure Form {116C}

FORM 116C - LIEN DISCLOSURE FORM. This form is used in the Commonwealth of Massachusetts Department of Industrial Accidents by employees involved in a workers' compensation settlement. The form requires the employee to certify, under penalty of perjury, that there are no outstanding liens or claims for reimbursement from various entities such as the Department of Transitional Assistance, Department of Revenue Child Support Services Division, Veterans Services, prior legal counsel, or any medical, dental, hospital, or disability income providers. The employee must also provide their workers' compensation DIA Board number(s) and personal information, including their social security number (which is optional but helps with processing). This certification ensures that the settlement proceeds are free of any undisclosed financial obligations. www.FormsWorkflow.com