Affidavit of Workers’ Compensation Payments

Category: #354 | Disability Retirement , Survivor Benefits , Application Form , Tier 1 , Tier 2 , Tier 3 , Tier 4 , Tier 6

Document Type: Application Form

Tier Number: Tier 1, Tier 2, Tier 3, Tier 4, Tier 6

File Number: 354

Form #354
Use this affidavit to report Workers’ Compensation payments you have received, and/or are currently receiving.

Affidavit of Workers' Compensation Payments