Description:
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Name
Application to Defer Payment of Filing Fees & Financial Affidavit
Number
14-0075
Last Updated
July 2023
Overview
This form is used to apply for deferment of the payment of filing fees that are required for some filings with DWC.
Instructions
- Download the form by clicking on the link above. Complete the form by providing the requested information.
- 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).
- Complete the Request section with the information required.
- Completed the Certificate of Service section.
- Complete the Oath and Signature section.
- Sign the form, swearing or affirming the accuracy of the information your provided.
- File the completed paper form with the DWC.
- Serve a copy of the other party or the other party's attorney.
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.