Form — Application to Defer Payment of Filing Fees & Financial Affidavit — 14-0075

File: 
PDF icon Application to Defer Payment of Filing Fees -- Form 14-0075 -- July 2019.pdf
Description: 

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Name

Application to Defer Payment of Filing Fees & Financial Affidavit

Number

14-0075

Last Updated

July 22, 2019

Overview

This form is used to apply for deferment of the payment of filing fees that are required for some filings with the Iowa Division of Workers' Compensation (DWC).

Instructions

  1. Download the form by clicking on the link above. Complete the form by providing the requested information.
  2. Complete the caption by providing in the corresponding blank the:
    • Name of the claimant
    • Name of the employer
    • Name of any insurance carrier
    • Name(s) of any other defendant(s)
    • Any agency file number(s)

NOTE:  In some cases, there is not an insurance carrier (e.g., when the employer is self-insured) or any other defendant(s).

  1. Complete the form.
  2. Notarize the form.
  3. File the completed paper form with the DWC.

Mandatory Paper Filing

You must file the paper version of this completed form with the DWC under agency rules. Do not electronically file (eFile) this form.