FILED Feb 13, 2019 01:08 PM(CT) TENNESSEE COURT OF WORKERS' COMPENSATION CLAIMS
TENNESSEE BUREAU OF WORKERS' COMPENSATION IN THE COURT OF WORKERS' COMPENSATION CLAIMS AT GRAY
GREGORY HARDIN, ) Docket Number: 2017-02-0333 Employee, ) v. ) W.A. KENDALL & CO., INC., ) State File Number: 4528-2017 Employer, ) and ) XL INSURANCE AMERICA, ) Judge Brian K. Addington Carrier. )
COMPENSATION HEARING ORDER
This case came before the Court January 24-28, 2019, for a compensation hearing. The legal issues are whether Mr. Hardin's claim is barred by willful misconduct, and if not, the amount of benefits due. The Court holds that Mr. Hardin suffered a compensable injury that was not barred by willful misconduct. As explained below, it awards him past and future lifetime medical benefits, temporary total and permanent partial disability benefits, and reasonable attorney's fees.
History of Claim
W.A. Kendall hired Mr. Hardin in January 2016 to work as a groundsman on its wood clearing crew. 1 It provided him with a handbook and laborer training manual, and he passed a test associated with the training manual. Later, he received on-the-job training to operate a wood chipper from his foreman, Dusty Shaffer, who instructed him to approach a chipper from the rear in an arc, use both hands to throw the material into the chipper, and continue in the arc while moving away to pick up another pile. These instructions mirrored the instructions in W .A. Kendall's handbook. 2
A couple of months later, Mr. Hardin and other employees received a written record of instruction on March 16, 2016, for feeding the chipper from behind instead of 1 Mr. Hardin's average weekly wage was $434.89, which provides a $289.93 compensation rate. 2 The materials reflect that W.A. Kendall's policies were more guidelines than inflexible rules.
1 from the side. The chipper also had stickers that warned operators to follow instructions in the operator's manual, always or constantly to remain in position to operate the control bar to stop the machine if necessary, and to never push items too far into the chipper.
On the day of the accident, January 18, 2017, Mr. Hardin and groundsman Brandon Moore were the only employees at the Wiseman worksite. Mr. Moore operated a leaf blower, while Mr. Hardin chipped brush. Mr. Hardin testified at trial that he picked up a bundle of brush, walked toward the chipper in an arc pattern, and fed it into the chipper. At that time, a vine entangled his right arm. He grabbed his right arm with his left in an attempt to draw back his right arm. The power of the machine caused him to lose his footing and fall face first onto the feed table. As the chipper started to pull his right hand into the rollers, he turned to his back and struck the control bar with his legs, stopping the chipper. He extracted himself from the machine, but the chipper severed his right hand, and he suffered partial amputation of his ear and significant facial lacerations.
Even though he did not witness the accident, Mr. Moore called 911. EMS responder Robert Wells conducted a scene survey while others attended Mr. Hardin. While assessing the scene, he backed away from Mr. Hardin and the chipper. In doing so, he tripped over a brush pile, which was located to the rear of the chipper and near the end of the gravel road leading to the upper reaches of the property. He testified he remembered the brush pile because tripping over it embarrassed him.
EMS transported Mr. Hardin to the hospital where he was hospitalized for five days. W. A. Kendall representatives visited him, but he was anesthetized and unable to provide any statement.
Dr. Benjamin Knox operated on Mr. Hardin and concluded his hand could not be saved. He referred Mr. Hardin to a prosthetist. Dr. Jim Brantner operated on his facial and ear lacerations. Upon release, the hospitalist, Dr. Melissa Powell, restricted Mr. Hardin's use of his right arm until an orthopedist cleared him. The hospital bills totaled $72,482.
After the hospital released him, Mr. Hardin continued to treat with Dr. Brantner, who never placed Mr. Hardin at maximum medical improvement (MMI) but did assign ten percent whole-body impairment for his facial injuries. Mr. Hardin received treatment for his hand injury from Dr. Kent Lord, who placed him at MMI on October 10, 2018, and assigned sixty percent whole-body impairment for injuries to his right arm. Dr. Lord noted Mr. Hardin was a good candidate for prosthesis and felt his permanent restrictions depended on the prosthesis he received.
Mr. Hardin went to Bristol Orthotics and Prosthetics for a prosthesis evaluation. There, Prosthetist and Orthotist Will Graybeal determined Mr. Hardin was a good prosthesis candidate and recommended three different orthotic hands, a body powered
2 arm, a body powered recreational arm, and a myo-electric !-limb arm. Together, they would enable him to do more complex activities, including up to ninety-five percent of the activities he previously performed. Neither Dr. Knox nor Dr. Lord reviewed Mr. Graybeal's recommendations.
W. A. Kendall did not speak with Mr. Hardin before it decided to deny his claim on January 27, and it refused to pay his medical bills or pay temporary disability benefits. On January 31, Mr. Hardin's attorney notified W.A. Kendall of his representation and requested a Panel of Physicians. W.A. Kendall formally filed a Notice of Denial on February 28 alleging Mr. Hardin was guilty of misconduct and had failed to follow a safety rule. It never provided a panel of physicians.
Mr. Hardin hired Charles Coones, a Certified Safety Professional, as an expert to recreate the chipping accident. Based on Mr. Hardin's account, Mr. Coones recreated the event using a similar machine and a fireman dummy. Mr. Coones concluded it was highly probable the chipper pulled him in as Mr. Hardin testified at trial.
W. A. Kendall hired Dr. Richard Ziernicki as its expert. 3 He relied on Mr. Hardin's deposition testimony as to where he was standing when the incident occurred, Mr. Moore's placement of the chipper, and circumstantial evidence from the scene. He concluded Mr. Hardin was not standing where he indicated but was to the rear of the chipper. He determined if Mr. Hardin was standing as he testified in his deposition, his body would have hit the control bar, and if he was not there, he violated W. A. Kendall's safety rules. He assumed that Mr. Hardin tried to flick materials that were in the hopper in violation of the rules. 4
Findings of Fact and Conclusions of Law
Mr. Hardin must prove all elements of his case by a preponderance of the evidence. Tenn. Code Ann. § 50-6-239(c)(6) (2018). As the threshold issue, Mr. Hardin must prove the compensability of his claim. Specifically, he must show he suffered "an injury by accident ... arising primarily out of and in the course and scope of employment." Tenn. Code Ann. § 50-6-102(14). If he establishes an injury, then Tennessee Code Annotated section 50-6-204(a)(l)(A) requires "[t]he employer or the employer's agent [to] furnish, free of charge to the employee, such medical ... treatment ... made reasonably necessary by accident[.]"
3 Both experts were well qualified to testify on the matter. 4 He came to this conclusion based on statements from employees that all the brush had already been cut, and that Mr. Hardin was just throwing rakings into the chipper.
3 Mr. Hardin suffered open and obvious injuries to his right hand, face and ear when the wood chipper pulled him in while working for W. A. Kendall. The Court holds by a preponderance of the evidence that he suffered an injury arising primarily out of and in the course and scope of his employment.
The Court must consider, however, whether Mr. Hardin's compensable injury was barred by willful misconduct. Tenn. Code Ann. § 50-6-llO(a)(l). W.A. Kendall has the burden to prove such defense. Tenn. Code Ann. § 50-6-110(b). It must prove Mr. Hardin violated a work rule; he had actual, as opposed to constructive notice of the rule; he understood the danger involved in violating the rule; the bona fide enforcement of the rule by W. A. Kendall; and, the lack of a valid excuse for violating the rule. Mitchell v. Fayetteville Pub, Utils., 368 S.W.3d 442, 453 (Tenn. 2012).
W. A. Kendall asserted that Mr. Hardin violated three rules: 1) he did not feed the wood chipper from the ditch side; 2) he reached his hand into the hopper; and 3) he was not in a position to control the safety bar as he operated the chipper. The Court will analyze each alleged rule violation using the elements set out in Mitchell.
Concerning the first rule, W.A. Kendall proved by a preponderance of the evidence that Mr. Hardin had notice. Its handbook and the operation manual stated the correct way to feed a chipper is by approaching it from the rear on the ditch side. Mr. Hardin testified he was aware of the danger in violating the rule and had been written up for violating it once, although he denied actually violating it. But he also testified that at the time of the accident, he was feeding the machine from the rear ditch side.
W.A. Kendall's expert concluded that if Mr. Hardin had been standing center mass on the ditch side of the feed table, his body would have engaged the safety bar as the chipper pulled him into the machine. He compared this to a fish on a taut line. However, the Court finds Mr. Hardin to be credible when he testified that he fought to free himself by grabbing his right arm with his left dominant arm. This would have changed his position and would not have prevented him from moving side to side or up and down as the machine pulled him in. Dr. Ziemicki's reenactment does not allow for such a scenario, only exhibiting a static dummy being pulled into the machine.
Dr. Ziernicki relied on Mr. Hardin's deposition testimony wherein he made an ink slash on a diagram that purportedly showed him "standing" in the middle of the feed table on the chipper's ditch side when he threw brush into it. In Dr. Ziemicki's reenactment, he positioned a man standing in the center of the ditch side of the feed table. However, the evidence does not support such positioning. Mr. Hardin testified and demonstrated that he was not "standing" anywhere but was walking as he fed the machine. Also, the mark on the chipper diagram is not proportional to the size of a human body when standing next to the machine. If it were, Mr. Hardin would be represented by a thin ink slash. Mr. Hardin did not intend to make a mark to indicate his body covered the width ofthe ditch side of the feed table.
4 W.A. Kendall's training manual and videos show an employee correctly approaching the chipper from the rear on the ditch side. Mr. Hardin testified he did the same on the date ofinjury. 5
Even if W.A. Kendall proved Mr. Hardin violated the rule, it failed to prove he did not have a valid excuse for doing so. The Court finds that on the day of the accident, Mr. Hardin fed the chipper as he was trained by his superiors, so if he violated the rule, W. A. Kendall failed to prove he lacked a valid excuse for doing so.
Concerning rule two, Dr. Ziernicki concluded that Mr. Hardin could not have been at the side of the feed table but was behind it reaching into the hopper, which was a violation of the rule. He came to this conclusion based on statements from Mr. Moore and others that there were no big items to throw into the chipper but just small rakings. He then assumed that the small clippings could have not made it to the rollers, and Mr. Hardin reached into the hopper to flick them into the rollers.
There was conflicting testimony on the pile of branches, as some employees did not see a large pile of branches after the accident. However, Mr. Wells testified as did Mr. Hardin that there was large brush still to be chipped at the scene. Mr. Wells recounted his embarrassment from falling in the pile. The Court finds his testimony highly credible. The preponderance of the evidence does not support W. A. Kendall's assertion that Mr. Hardin reached into the hopper because there were only small clippings left to be chipped.
As to the notice about the safety bar, the Court does not consider it a rule, but a warning. Nonetheless, every person who described operating the chipper or demonstrated its use for a video illustrated using both hands to throw brush into the chipper. It would be anatomically impossible to grab the control bar at all times during the feeding/chipping process. Therefore, even if it were a rule, Mr. Hardin had a valid excuse for violating it.
Because the Court holds that Mr. Hardin suffered a compensable injury, he is entitled to necessary and reasonable medical benefits. He proved his work-r lated injm was primarily responsible for his need for medical treatment. 6 Thus, the CoUJt holds W.A. Kendall shall pay for all emergency treatment that Mr. Hardin received at the hospital in the amount of $72,482.
5 The Court notes a slight discrepancy between Mr. Hardin's trial testimony and his deposition testimony, but the Court finds it inconsequential. Mr. Hardin repeated at trial on direct and cross as to what happened on the date of the injury. The Court notes he did not waiver in his testimony at trial. 6 This information is contained in the C-32s from Drs. Lord and Brantner.
5 Mr. Hardin requested a panel of physicians for his compensable injury on January 31, 2017, which W. A. Kendall denied. The Court holds Mr. Hardin was reasonable in seeking treatment with Drs. Knox, Lord, and Brantner. W.A. Kendall shall pay for Mr. Hardin's prior treatment and ongoing medical treatment with these physicians that is related to his injury. As to Mr. Hardin's request for approval of Mr. Graybeal's prosthetic arm recommendations, the Court holds this issue is best left to physicians. Mr. Hardin must return to Dr. Knox or Dr. Lord for a determination of the prosthetic devices that are reasonable and necessary for his injury. 7
Concerning temporary total disability benefits, Mr. Hardin must prove by a preponderance of the evidence: (1) a disability from working as the result of a compensable injury; (2) a causal connection between the injury and the inability to work; and (3) the duration of the period of disability. Shepherd v. Haren Canst. Co., Inc., 2016 TN Wrk. Comp. App. Bd. LEXIS 15, at *13 (Mar. 30, 2016). Dr. Melissa Powell restricted Mr. Hardin's use of his right arm until he was cleared by an orthopedist. Dr. Lord found that Mr. Hardin's injury had caused him to miss work and did not place him at MMI until October 8, 2018. Thus, Mr. Hardin proved entitlement to temporary total disability benefits of $26,010.87. 8
Regarding permanent partial disability benefits, an employee who establishes a partial disability from a compensable permanent injury is entitled to payment of permanent partial disability benefits for the number of weeks calculated by multiplying the applicable impairment rating by 450 weeks. Tenn. Code Ann. § 50-6-207(3)(A). These benefits are paid at the weekly compensation rate whether or not the employee returns to work. !d. The Workers' Compensation Law refers to this as the original award. Dr. Lord assigned a sixty percent impairment rating to the whole body. 9 Therefore, the Court finds he sustained a sixty percent permanent partial impairment. This equates to an original award of 270 weeks benefits or $78,281.10.
Finally, Mr. Hardin requested attorney fees for W.A. Kendall's wrongful denial of his claim. The Court holds Mr. Hardin is entitled to the requested fees.
Tennessee Code Annotated section 50-6-226( d)(l )(B) allows the Court to award reasonable attorney's fees and costs when an employer wrongfully denies a claim or fails
7 Dr. Lord referred Mr. Hardin for a prosthetic-orthotic evaluation, and the Court found Prosthetist Graybeal qualified to testifY as an expert at trial. However, the specific types of prosthetics recommended were not ordered by Dr. Lord or Dr. Knox. 8 This amount represents eighty-nine weeks and five days, as 20 16 was a leap year. 9 Although Dr. Brantner's impairment rating was entered as exhibit twenty-four, Dr. Brantner never placed Mr. Hardin at MMI, and Mr. Hardin did not request permanent disability payments based on Dr. Brantner's rating in his pre-hearing statement or at trial.
6 to timely initiate benefits. At the time of Mr. Hardin's injury, the statute did not define the term "wrongfully." However, in a 2018 amendment, the Legislature defined "wrongfully" to mean "erroneous, incorrect, or otherwise inconsistent with the law or facts." In Andrews v. Yates Serv., LLC, 2018 TN Wrk. Comp. App. Bd. LEXIS 22 (May 8, 20 18), the Appeals Board held that, although the amended definition does not directly apply to injuries prior to its enactment, like Mr. Hardin's injury, a court should "look to the new statute as persuasive authority in evincing the General Assembly's original intent." /d. at *9.
In Andrews, the Board concluded that:
a trial court may consider whether an employer's decision to deny a claim was erroneous, incorrect, or otherwise inconsistent with the law or facts at the time the denial decision was made. Thus, it is within a trial court's discretion to consider an employer's decision to deny a claim in light of evidence or other information reasonably available to the employer at the time the claim was denied.
/d. at *12 (Emphasis added).
Applying that authority here, the Court holds W. A. Kendall's actions at the time it denied Mr. Hardin's claim were erroneous, incorrect, and inconsistent with the facts. Namely W.A. Kendall did not speak with Mr. Hardin before its denial, relied upon only circumstantial evidence, 10 and had no expe1i proof at that time which establjshed Mr. Hardin's alleged misconduct. The investigation undertaken by W.A. Kendall "at the time the denial decision was made" was inadequate to establish its willful misconduct defense and, thus, was inconsistent with a complete picture of the facts as of the date of denial.
Therefore, the Court holds that Mr. Hardin should be awarded attorney fees. Mr. Hardin's attorney shall submit an accounting of his time and hourly rate with an affidavit for consideration of attorney fees. He shall also simultaneously submit a request for reasonable and necessary costs. W.A. Kendall shall have five business days to respond.
IT IS, THEREFORE, ORDERED as follows: 1. The Court designates Drs. Knox, Lord, and Brantner as Mr. Hardin's authorized physician. Mr. Hardin is awarded a judgment of $72,482 against W.A. Kendall for past medical expenses, and W. A. Kendall shall provide reasonable and necessary future medical treatment under Tennessee Code Annotated section 50-6- 204(a)(l)(A).
2. Mr. Hardin is awarded a judgment of $26,010.87 against W.A. Kendall for past temporary total disability benefits. 10 Mr. Hardin was the only eyewitness to the accident.
7 3. Mr. Hardin is awarded a judgment of $78,281.10 against W. A. Kendall for temporary total disability benefits. All incurred benefits shall be paid in lump sum with the remaining in weekly benefits.
4. Mr. Hardin's attorney shall submit an accounting of his time and hourly rate with an affidavit for consideration of attorney fees. He shall also simultaneously submit a request for reasonable and necessary costs. W.A. Kendall shall have five business days to respond.
5. W.A. Kendall shall pay $150.00 costs to the Court Clerk within five business days under Tennessee Compilation Rules and Regulations 0800-02-21-.07.
6. W.A. Kendall shall prepare and submit a Statistical Data Form (SD2) within five business days of this order becoming final.
7. W. A. Kendall failed to timely file a notice of denial or provide a panel to which Mr. Hardin was entitled. The Court refers the case to the Bureau's Compliance Unit for consideration of a penalty.
8. Absent an appeal, this order shall become final in thirty days after issuance.
ENTERED this the 13th day of February, 2019.
IS/ Brian K. Addington BRIAN K. ADDINGTON, JUDGE Court of Workers' Compensation Claims
APPENDIX
Exhibits: 1. Statement ofUnderstanding 2. Photo 3. Collective Exhibit-Photo (3) 4. Photo 5. Phot 6. Photo 7. Collective "' xhibit-Photos (4) 8. Employee s Choice of Physician Form 9. Photo lO.Photo
8 11. Photo 12. Labor Training Manual 13. Test for Labor Training 14. Job Safety Analysis Form 15. Employee Handbook 16. Target Training Form 17. Collective Diagram (Deposition Exhibit 3) 18.Mentor Progress Sheet 19. MedicOne Medical Response 20. Johnson City Medical Center-Billing Statement 21. Photo 22. Johnson City Medical Center records 23. Standard Form Medical Report-Dr. Kent Lord 24. Standard Form Medical Report-Dr. Jim Brantner 25. Mortality Table 26. Prosthetist License of Will Graybeal 27. Orthotist License of Will Graybeal 28. Video-Limb Prosthetics 29. Recommended Prosthetic Hands Chart 30. Bristol Orthotics and Prosthetics records 31. Referral Order Dr. Benjamin Knox 32. Curriculum Vitae of Charles Coones 33. Forensic Investigations and Technologies preliminary report 34. Forensic Investigations and Technologies supplemental report 3 5. Demonstration video-Charles Coones 36. License Status Website (identification purposes) 3 7. Wage Statement 38.Notice ofDenial of Claim 39. TOSHA Report (identification purposes) 11 40. Video-Dr. Richard Ziernicki 41. Analysis of the Hazards of Wood Chipper Accidents 42. Video-W.A. Kendall demonstration video 43. Kendall Record of Instruction or Correction 44. Collective Exhibit-Photos (4 7) 45. New employee training video 46. Brandon Moore's Deposition 47. Brandon Moore's Affidavit 48. Affidavit of Criminal Complaint, Brandon Moore 49. Criminal Court Judgment, Brandon Moore 11 The Court reserved ruling on the admissibility of this document until it had an opportunity to review the Appeals Board's decision in Kizer v. Express Servs. Inc., 2018 TN Wrk. Comp. App. Bd. LEXIS 17 (Apr. 20, 20 18). Based on the holding in Kizer, the Court finds W.A. Kendall did not lay a proper foundation for this document.
9 50. Criminal Plea, Brandon Moore 51. Robert Williams' Deposition 52. Letter dated January 31, 2017 53.Email 54. Handwritten statements (identification purposes)
Technical Record:
1. Petition for Benefit Determination 2. Dispute Certification Notice 3. Employer's Motion to Compel HIPAA Release 4. Employee's Response to Motion to Compel HIPPA Release 5. Order Compelling Discovery 6. Employee's Notice of Compliance 7. Employee's Request for Scheduling Hearing 8. Scheduling Hearing Order 9. Employee's Motion for Permission to Serve Additional Interrogatories 10. Order Granting Additional Interrogatories 11. Employee's Motion to Amend Scheduling Order 12. Employer's Response to Motion to Amend 13. Order Granting Extension of Deadlines 14. Employer's Witness List 15. Employee's Witness List 16.Employee's Notice of Intent to Use C-32 17. Employer's Motion to File a Brief Exceeding Ten Pages 18.Employee's Motion in Limine 19.Employee's Motion to Exclude Discovery Depositions 20. Employee's Motion to Compel Expert Witness' Investigative File 21. Employee's Motion to File a Brief Exceeding Ten Pages 22. Post Discovery DCN 23. Employer's Response to Motion to Exclude Discovery Depostions 24. Employer's Response to Motion in Limine 25. Employee's Objection to Employer's Untimely Filing of Responses to Motions 26. Court Order on Motions 27. Employee's List of Proposed Exhibits 28. Employee's Pre-Compensation Hearing Statement 29. Employee's Pre-Compensation Hearing Brief 30. Employer's List of Proposed Exhibits 31. Employer's Pre-Compensation Hearing Statement 32. Employer's Notice of Filing Proposed Exhibits 33. Employer's Pre-Hearing Brief
10 13 II I 'I
Compensation Hearing Order Right to Appeal:
If you disagree with this Compensation Hearing Order, you may appeal to the Workers' Compensation Appeals Board or the Tennessee Supreme Court. To appeal to the Workers' Compensation Appeals Board, you must:
1. Complete the enclosed form entitled: "Compensation Hearing Notice of Appeal," and file the form with the Clerk of the Court of Workers' Compensation Claims within thirty calendar days of the date the compensation hearing order was filed. When filing the Notice of Appeal, you must serve a copy upon the opposing party (or attorney, if represented).
2. You must pay, via check, money order, or credit card, a $75.00 filing fee within ten calendar days after filing of the Notice of Appeal. Payments can be made in-person at any Bureau office or by U.S. mail, hand-delivery, or other delivery service. In the alternative, you may file an Affidavit of Indigency (form available on the Bureau's website or any Bureau office) seeking a waiver ofthe filing fee. You must file the fully- completed Affidavit of Indigency within ten calendar days of filing the Notice of Appeal. Failure to timely pay the filing fee or file the Affidavit of lndigency will result in dismissal of your appeal.
3~ You bear the responsibility of ensuring a complete record on appeal. You may request from the court clerk the audio recording of the hearing for a $25.00 fee. A licensed court reporter must prepare a transcript and file it with the court clerk within fifteen calendar days of the filing the Notice of Appeal. Alternatively, you may file a statement of the evidence prepared jointly by both parties within fifteen calendar days of the filing of the Notice of Appeal. The statement of the evidence must convey a complete and accurate account of the hearing. The Workers' Compensation Judge must approve the statement of the evidence before -the record is submitted to the Appeals Board. If the Appeals Board is called upon to review testimony or other proof concerning factual matters, the absence of a transcript or statement of the evidence can be a significant obstacle to meaningful appellate review.
4. After the Workers' Compensation Judge approves the record and the court clerk transmits it to the Appeals Board, a docketing notice will be sent to the parties. The appealing party has fifteen calendar days after the date of that notice to submit a brief to the Appeals Board. See the Practices and Procedures of the Workers' Compensation Appeals Board.
To appeal your case directly to the Tennessee Supreme Court, the Compensation Hearing Order must be final and you must comply with the Tennessee Rules of Appellate Procedure. If neither party timely files an appeal with the Appeals Board, the trial court's Order will become final by operation of law thirty calendar days after entry. See Tenn. Code Ann.§ 50-6-239(c)(7). For self-represented litigants: Help from an Ombudsman is available at 800-332-2667. II I. ' I
Tennessee Bureau of Workers' Compensation 220 French Landing Drive, 1-B Nashville, TN 37243-1002 800-332-2667
AFFIDAVIT OF INDIGENCY
I, , having been duly sworn according to law, make oath that because of my poverty, I am unable to bear the costs of this appeal and request that the filing fee to appeal be waived. The following facts support my poverty.
1. Full Name:_ _ _ _ __ _ _ _ _ __ 2. Address: - - - - - - - -- - - --
3. Telephone Number: - - - - - - - - - 4. Date of Birth: - - - - -- - - -- -
5. Names and Ages of All Dependents:
- - - - - - - - - - - - - - -- - Relationship: - - - - - - -- - - -- -
- - - - - - - - - - - - - -- -- Relationship: - - - - - -- - - -- - -
- - - - - - - - - - -- - -- - - Relationship: - - - -- - -- - - - - -
- - - - - - - - - - - - - - -- - Relationship: - - - - - - -- - - -- -
6. I am employed by: - - - - - - - - - - -- - - -- - - - - - -- - - -- - -
My employer's address is: - - - - -- - - - -- - - - - - -- - -- - - - -
My employer's phone number is: - - - -- - - - -- - - - - - -- - - -- - -
7. My present monthly household income, after federal income and social security taxes are deducted, is:
$ _ _ _ _ _ __
8. I receive or expect to receive money from the following sources:
AFDC $ per month beginning SSI $ per month beginning Retirement $ per month beginning Disability $ per month beginning Unemployment $ per month beginning Worker's Camp.$ per month beginning Other $ per month beginning
LB-1108 (REV 11/15) RDA 11082 9. My expenses are: ! ~ li I '
Rent/House Payment $ per month Med icai/Dental $ _ _ ___ per month
Groceries $ per month Telephone $ _ __ _ _ per month Electricity $ per month School Supplies $ _ _ _ _ _ per month Water $ per month Clothing $ _ _ _ _ _ per month Gas $ per month Child Care $ _ _ _ _ _ per month Transportation $ per month Child Support $ _ _ _ _ _ per month Car $ per month Other $ per month (describe:
10. Assets:
Automobile $ _ _ _ __ (FMV) - - - - - - - - - - Checking/Savings Acct. $ _ _ _ __ House $ _ _ __ (FMV) - - - - - - - - - - Other $ _ _ _ __ Describe:_ _ _ _ __ _ __ __
11. My debts are:
Amount Owed To Whom
I hereby declare under the penalty of perjury that the foregoing answers are true, correct, and complete and that I am financially unable to pay the costs of this appeal.
APPELLANT
Sworn and subscribed before me, a notary public, this
____ dayof _____________________ , 20_ __
NOTARY PUBLIC
My Commission Expires:_ _ _ _ _ _ __
LB-1108 (REV 11/15) RDA 11082