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Form 14-0075 - Application To Defer Payment Of Filing Fees, Financial Affidavit And Order

BEFORE THE IOWA WORKERS’ COMPENSATION COMMISSIONER

________________________________________________________________________

Claimant,

File No. _____________

vs.

APPLICATION TO DEFER

PAYMENT OF FILING FEES,

Employer,

FINANCIAL AFFIDAVIT AND ORDER

and

Insurance Carrier,

Defendants.

_________________________________________________________________________

I, the undersigned, hereby request the Iowa Workers’ Compensation Commissioner to

accept for filing my Original Notice and Petition without prepayment of filing fee(s). I hereby

state that if I am unable to defer the filing fee(s) in this matter, I would be unable to maintain

this action, and there is no reasonable alternative means for procuring the filing fee(s). I

understand that if the Original Notice and Petition is accepted for filing without prepayment of

the filing fee(s), provision for the payment of the filing(s) must be included in any settlement

submitted to the Workers’ Compensation Commissioner for approval, or taxed as costs as

part of a hearing on my petition.

In support of my request, I hereby submit the following affidavit under oath (attach

additional sheets if necessary).

Form 14-0075 - Application To Defer Payment Of Filing Fees, Financial Affidavit And Order