The opinion
FILED
May 11, 2018
10:23 AM(CT)
TENNESSEE COURT OF
WORKERS' COMPENSATION
CLAIMS
TENNESSEE BUREAU OF WORKERS’ COMPENSATION
IN THE COURT OF WORKERS’ COMPENSATION CLAIMS
AT MURFREESBORO
JAMES S. MACKIE, ) Docket No. 2016-05-1159
Employee, )
)
v. )
)
NATIONWIDE LOGISTICS, LLC, ) State File No. 40476-2016
Employer, )
)
And )
)
NORTHSTONE INS. CORP., ) Judge Dale Tipps
Insurer. )
EXPEDITED HEARING ORDER GRANTING BENEFITS
This matter came before the Court on May 3, 2018, for an Expedited Hearing.
The present focus of this case is whether Mr. Mackie is entitled to medical and temporary
disability benefits for his alleged back and chest injuries. The central legal issues are
whether he is likely to establish at a hearing on the merits that he gave adequate notice of
his alleged injury and whether it arose primarily out of and in the course and scope of his
employment. For the reasons below, the Court finds that Mr. Mackie is likely to prove
that he gave proper notice but cannot find he is likely to prove his injuries arose primarily
out of and in the course and scope of his employment. However, he is entitled to a panel
of physicians.
History of Claim
Mr. Mackie worked for Nationwide Logistics as a mechanic. On May 10, 2016,
he was working on a skid loader when the loader’s tire came loose. Mr. Mackie fell on
his back, and the tire landed on his chest. Because he was working the evening shift, no
supervisor was present. Mr. Mackie was in pain and had breathing problems, but he
finished his shift and went home.
1
The next morning, Mr. Mackie went to Vickie Mitchell, FNP, his primary care
provider. He also called his supervisor, Mark Russell, and told him about the accident.
Mr. Mackie told Mr. Russell he would not be at work that day. He returned to work on
May 12 but was unable to finish his shift because of pain and breathing difficulties. Mr.
Mackie went to St. Thomas Rutherford emergency room that evening, and the hospital
admitted him until his discharge on May 19. Nationwide did not provide a panel of
physicians or pay for Mr. Mackie’s medical treatment.
After the hospital released Mr. Mackie, Nationwide sent him to Dr. Samuel Sells
for a fitness determination. Based on Dr. Sells’ examination and restrictions, Nationwide
terminated Mr. Mackie. He has not worked anywhere since his injury.
The parties offered a number of medical records as exhibits to the hearing. The
earliest of these records is a Commercial Driver medical report that pre-dates Mr.
Mackie’s alleged injury. In June 2012, Dr. Sells examined Mr. Mackie and noted
“abnormal and diminished breath sounds (R) lung compared to (L) lung.” Noting he was
a forty-year smoker, Dr. Sells recommended a complete work-up with a chest x-ray and
advised Mr. Mackie to stop smoking.
Records from FNP Mitchell show that she saw Mr. Mackie for complaints of back
pain the day after the work accident. He reported pulling a muscle “one week ago” and
having some spasms and intermittent pain since then. Mr. Mackie also told FNP Mitchell
about his work accident the day before and stated he “pulled his back severely.” He said
he was “in severe pain, can’t sit or stand for longer than 5 minutes, can’t lie down, is
clammy.” FNP Mitchell noted swelling, tenderness, and intermittent spasm in Mr.
Mackie’s back. She prescribed pain medicine and muscle relaxer and told him to go the
emergency room if his condition did not improve.
St. Thomas Rutherford records show that Mr. Mackie went to the emergency
department a little after midnight on May 13 with complaints of abdominal pain, nausea,
shortness of breath, and radiating back pain. In one record, Mr. Mackie described pain
that began when a large tire hit him in the chest at work two days earlier. In another
record, he described the tire accident but noted he was having discomfort before it
occurred. Specifically, he reported the onset of right upper quadrant pain and shortness
of breath on Sunday, May 8, which prevented him from lying flat to sleep. Imaging
studies showed a right pleural effusion, and Mr. Mackie underwent a thoracentesis
procedure and placement of a chest tube.
Mr. Mackie’s diagnostic tests included a thoracic MRI. These films showed a
small disk bulge, so Dr. Michael Moran provided a neurosurgery consult. He noted “a
T7-T8 right paracentral chronic disk osteophyte complex which abuts the cord but does
not severely compress it.” Dr. Moran determined the “incidentally discovered” disc
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bulge was not clinically significant and required no further workup or treatment.
Infectious disease specialist Rakesh Kumar provided another consultation. He
noted Mr. Mackie’s history of pain and increasing shortness of breath beginning about a
week before his hospital admission as well as a chronic cough that gradually worsened.
Dr. Kumar attributed the pleural effusion to empyema with right lower lobe pneumonia,
both of which he treated with numerous antibiotics. He also related Mr. Mackie’s
abdominal and back pain to the pneumonia and empyema.
After leaving the hospital, Mr. Mackie followed up with Dr. Moran. Dr. Moran
noted some mechanical thoracic muscular pain but no myleopathic signs or symptoms.
He sent Mr. Mackie for a few physical therapy visits but felt no neurosurgical treatment
was necessary.
In addition to his 2016 medical records, Mr. Mackie submitted more recent
records from FNP Mitchell. Her note of April 9, 2018, reflects complaints of ongoing,
throbbing pain in Mr. Mackie’s mid-back with tingling in his fingers. FNP Mitchell also
noted swelling in his cervical/thoracic paraspinous muscles.
Both parties submitted causation opinions. Mr. Mackie offered a September 2017
letter by FNP Mitchell. She stated she saw him twelve times since July 2016 and his
symptoms consistently included worsening thoracic pain with radicular pain and
numbness. She concluded, “It is my opinion that his injury was caused by his work
accident. He didn’t have these symptoms prior to the injury.” Dr. Gertrude Stone signed
her name underneath FNP Mitchell’s signature.
Nationwide sent a causation questionnaire to Dr. Moran asking him to review Mr.
Mackie’s medical records. It asked: “[C]an you state within a reasonable degree of
medical certainty that Mr. Mackie’s current complaints of back pain, primarily arose out
of (i.e. more than 50%) his alleged work-injury of May 10, 2016, at Nationwide, Express,
Inc.?” Dr. Moran checked the “No” box.
Nationwide sent a similar questionnaire to Dr. Kumar about Mr. Mackie’s “current
complaints of right upper quadrant pain and shortness of breath.” Dr. Kumar also
responded “No.”
Mr. Mackie requested that the Court order Nationwide to provide additional
medical treatment, payment of his past medical bills, and payment of temporary disability
benefits.
Nationwide countered that Mr. Mackie is not entitled to workers’ compensation
benefits. It contended that his failure to provide timely notice bars his claim. Further,
Nationwide argued that Mr. Mackie failed to establish that he is likely to prove that his
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work was the primary cause of his condition.
Findings of Fact and Conclusions of Law
Mr. Mackie need not prove every element of his claim by a preponderance of the
evidence in order to obtain relief at an expedited hearing. Instead, he must come forward
with sufficient evidence from which this Court might determine he is likely to prevail at a
hearing on the merits. Tenn. Code Ann. § 50-6-239(d)(1) (2017); McCord v. Advantage
Human Resourcing, 2015 TN Wrk. Comp. App. Bd. LEXIS 6, at *7-8, 9 (Mar. 27, 2015).
Notice
Tennessee Code Annotated section 50-6-201(a)1 provides that an injured
employee must give written notice of an injury within thirty days unless it can be shown
that the employer had actual knowledge of the accident or that “reasonable excuse for
failure to give the notice is made to the satisfaction of the tribunal.” Mr. Mackie
submitted no proof that he provided written notice of an injury. Likewise, he offered no
proof that Nationwide had actual knowledge of his alleged injury. However, he testified
that he gave verbal notice to his supervisor the day after the accident. This suggests he
might have a reasonable excuse for failure to give written notice, especially since
Nationwide presented no evidence to rebut Mr. Mackie’s testimony or to support its
notice defense.
Further, Nationwide presented no evidence of any prejudice to its ability to defend
this claim. Tennessee Code Annotated section 50-6-201(a)(3) provides that failure to
give notice will not bar a claim unless the employer can show it was prejudiced by the
lack of notice. In the absence of any evidence on this issue, the Court cannot find Mr.
Mackie’s alleged failure to report the injury resulted in any prejudice to Nationwide, such
as a serious impediment to investigating the claim. Therefore, the Court finds that Mr.
Mackie appears likely to prevail at a hearing on the merits on the issue of notice.
Compensability
To prove a compensable injury, Mr. Mackie must show that his alleged injury
arose primarily out of and in the course and scope of his employment. To do so, he must
show his injury primarily arose out of a work-related incident, or specific set of incidents,
identifiable by time and place of occurrence. Further, he must show, “to a reasonable
degree of medical certainty that it contributed more than fifty percent (50%) in causing
the . . . disablement or need for medical treatment, considering all causes.” “Shown to a
reasonable degree of medical certainty” means that, in the opinion of the treating
1
Section 201 currently requires notice within fifteen days. However, the amendment establishing the
fifteen-day deadline did not take effect until July 1, 2016.
4
physician, it is more likely than not considering all causes as opposed to speculation or
possibility. See Tenn. Code Ann. § 50-6-102(14) (2016).
Applying these principles to the facts of this case, the Court first notes that
Nationwide presented no testimony or other proof to contradict Mr. Mackie’s description
of the accident he suffered at work on May 10, 2016. The Court found his testimony
credible, but more importantly, it was unrebutted. Thus, no genuine dispute exists that
Mr. Mackie established a specific incident, identifiable by time and place. The question
to be resolved, therefore, is whether he appears likely to prove at a hearing on the merits
that his work was the primary cause of the injury. The Court cannot find at this time that
Mr. Mackie is likely to meet this burden.
Both parties presented opinions related to causation. Mr. Mackie relied on FNP
Mitchell’s letter in which she stated her opinion that Mr. Mackie’s injury “was caused by
his work accident.” The Court cannot credit FNP Mitchell’s opinion with any weight
because a nurse practitioner is not competent to provide a causation opinion. See Dorsey
v. Amazon.com, Inc., 2015 TN Wrk. Comp. App. Bd. LEXIS 13 at *9-10 (May 14, 2015).
Although the letter also contained the signature of Dr. Gertrude Stone, Mr. Mackie
presented no evidence as to whether Dr. Stone concurred with FNP Mitchell’s opinion or
merely signed the letter for a more generic purpose, such as signing off as her supervising
physician. Without more information, the Court is unable to ascribe FNP Mitchell’s
opinion, drafted on her own letterhead, to a physician whose role in this matter is
completely unknown.
The Court admitted into evidence two medical opinions proffered by Nationwide,
those of Drs. Moran and Kumar. Both doctors were asked, “[C]an you state within a
reasonable degree of medical certainty” that Mr. Mackie’s current complaints primarily
arose out of his alleged work-injury. While both doctors answered “No,” the wording of
the question leaves it unclear whether they meant that they were unable to give an
opinion “within a reasonable degree of medical certainty” or whether they had an opinion
that the injury did not primarily arise out the work injury.
Further, the question posed to Dr. Kumar was defective in that it asked him only
whether Mr. Mackie’s current complaints of right upper quadrant pain and shortness of
breath primarily arose out of his work injury. As Mr. Mackie is not alleging current
symptoms of this nature, the question is irrelevant as worded. Instead, it should have
addressed the cause of the complaints for which Dr. Kumar provided treatment in 2016.
Because FNP Mitchell’s opinion is inadmissible and the doctors’ opinions are too
ambiguous to be reliable, the Court has no medical opinion addressing the cause of Mr.
Mackie’s condition. Absent any such opinion, the Court cannot find he is likely to prove
“to a reasonable degree of medical certainty” that his work “contributed more than fifty
percent (50%) in causing the . . . disablement or need for medical treatment, considering
5
all causes.” However, additional analysis is required in light of Nationwide’s failure to
provide any initial medical treatment.
The Workers’ Compensation Law requires employers to timely provide a panel to
injured employees who come forward with evidence of a work-related injury. See Tenn.
Code Ann. § 50-6-204 and Tenn. Comp. R. & Regs. 0800-02-01-.25. An employer who
fails to comply with this rule without good cause could be assessed a civil penalty up to
$5,000.00. Id. Because of this requirement, an employee who comes forward at an
expedited hearing with sufficient evidence that a work event resulted in injury may be
entitled to an order compelling an employer to provide a panel. See Lewis v. Molly Maid,
2016 TN Wrk. Comp. App. Bd. LEXIS 19, at *8-9 (Apr. 20, 2016). In McCord, the
Workers’ Compensation Appeals Board found that:
[W]hether the alleged work accident resulted in a compensable injury has
yet to be determined. Therefore, while Employee has not proven by a
preponderance of the evidence that she suffered an injury arising primarily
out of and in the course and scope of employment, she has satisfied her
burden at this interlocutory stage to support an Order compelling Employer
to provide a panel of physicians.
McCord at *16, 17. Thus, the question is whether Mr. Mackie has provided sufficient
evidence to satisfy his “burden at this interlocutory stage” that he is entitled to a panel of
physicians.
Mr. Mackie’s version of events was the only proof presented at the hearing
regarding the details of his workplace injury. He testified that he injured himself on May
10, 2016, and reported the problem to his supervisor the next day. Nationwide presented
no evidence to refute Mr. Mackie’s description of these events. Thus, the undisputed
evidence establishes that Mr. Mackie promptly reported a work injury to Nationwide.
Nationwide offered no proof as to why it failed to provide a panel. Instead, it
questioned whether Mr. Mackie’s problems pre-existed his May 10 accident, noting that
his medical records described symptoms present before that date. These concerns are
understandable, but they do not excuse Nationwide from its statutory duty to provide
medical treatment once it received notice of a work injury. The Court is constrained to
the record before it, because “judges, like lawyers, are poorly positioned to formulate
expert medical opinions.” Love v. Delta Faucet Co., 2016 TN Wrk. Comp. App. Bd.
LEXIS 45, at *15-16 (Sept. 19, 2016). Similarly, parties cannot rely solely on their own
medical interpretations to support their arguments. Lurz v. Int’l Paper Co., 2018 TN
Wrk. Comp. App. Bd. LEXIS 8, at *17 (Feb. 14, 2018). Further, Nationwide’s argument
overlooks the question of whether the work injury might have aggravated any preexisting
conditions.
6
Therefore, the Court finds Mr. Mackie provided sufficient evidence to satisfy his
burden at this interlocutory stage that he is entitled to a panel of physicians. Nationwide
is ordered to provide a panel from which Mr. Mackie may choose an authorized
physician for evaluation and, if appropriate, treatment of his alleged injuries in
accordance with Tennessee Code Annotated section 50-6-204(a)(1)(A).
Temporary Disability Benefits
Mr. Mackie also seeks payment of temporary disability benefits. An injured
worker is eligible for temporary total disability benefits if: (1) the worker became
disabled from working due to a compensable injury; (2) there is a causal connection
between the injury and the inability to work; and (3) the worker established the duration
of the period of disability. Jones v. Crencor Leasing and Sales, TN Wrk. Comp. App.
Bd. LEXIS 48, at *7 (Dec. 11, 2015). As noted above, Mr. Mackie failed to prove he is
likely to meet his burden of proving a work-related injury. Therefore, the Court cannot
find at this time that he appears likely to prevail on a claim for temporary disability
benefits at a hearing on the merits.
IT IS, THEREFORE, ORDERED as follows:
1. Nationwide shall provide Mr. Mackie with a panel of physicians and any medical
treatment made reasonably necessary by his May 10, 2016 injury in accordance
with Tennessee Code Annotated section 50-6-204.
2. Mr. Mackie’s request for temporary disability benefits is denied at this time.
3. This matter is set for a Scheduling Hearing on July 19, 2018, at 9:00 a.m. The
parties must call 615-741-2112 or toll-free at 855-874-0473 to participate. Failure
to call in may result in a determination of the issues without the parties’
participation. All conferences are set using Central Time (CT).
4. Unless interlocutory appeal of the Expedited Hearing Order is filed, compliance
with this Order must occur no later than seven business days from the date of entry
of this Order as required by Tennessee Code Annotated section 50-6-239(d)(3).
The Insurer or Self-Insured Employer must submit confirmation of compliance
with this Order to the Bureau by email to WCCompliance.Program@tn.gov no
later than the seventh business day after entry of this Order. Failure to submit the
necessary confirmation within the period of compliance may result in a penalty
assessment for non-compliance.
5. For questions regarding compliance, please contact the Workers’ Compensation
Compliance Unit via email at WCCompliance.Program@tn.gov.
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ENTERED this the 11th day of May, 2018.
_____________________________________
Judge Dale Tipps
Court of Workers’ Compensation Claims
APPENDIX
Exhibits:
1. Affidavit of James Scott Mackie
2. Nationwide’s indexed medical records
3. Mr. Mackie’s indexed medical records
4. Wage Statement
Technical record:
1. Request for Expedited Hearing
2. Dispute Certification Notice
3. Nationwide’s Response to Request for Expedited Hearing
CERTIFICATE OF SERVICE
I hereby certify that a true and correct copy of the Expedited Hearing Order was
sent to the following recipients by the following methods of service on this the 11th day
of May, 2018.
Name Certified Fax Via Service sent to:
Mail Email
Richard L. Dugger, X rldugger55@yahoo.com
Employee’s Attorney cc:
gprwinsett710@gmail.com
Chad Jackson, X cjackson@morganakins.com
Employer’s Attorney
_____________________________________
Penny Shrum, Clerk of Court
Court of Workers’ Compensation Claims
WC.CourtClerk@tn.gov
8
Expedited Hearing Order Right to Appeal:
If you disagree with this Expedited Hearing Order, you may appeal to the Workers’
Compensation Appeals Board. To appeal an expedited hearing order, you must:
1. Complete the enclosed form entitled: “Expedited Hearing Notice of Appeal,” and file the
form with the Clerk of the Court of Workers’ Compensation Claims within seven
business days of the date the expedited hearing order was filed. When filing the Notice
of Appeal, you must serve a copy upon all parties.
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 of the 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 Indigency will
result in dismissal of the 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. If a transcript of
the proceedings is to be filed, a licensed court reporter must prepare the transcript and file
it with the court clerk within ten business days of the filing the Notice of
Appeal. Alternatively, you may file a statement of the evidence prepared jointly by both
parties within ten business 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 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. If you wish to file a position statement, you must file it with the court clerk within ten
business days after the deadline to file a transcript or statement of the evidence. The
party opposing the appeal may file a response with the court clerk within ten business
days after you file your position statement. All position statements should include: (1) a
statement summarizing the facts of the case from the evidence admitted during the
expedited hearing; (2) a statement summarizing the disposition of the case as a result of
the expedited hearing; (3) a statement of the issue(s) presented for review; and (4) an
argument, citing appropriate statutes, case law, or other authority.
For self-represented litigants: Help from an Ombudsman is available at 800-332-2667.
Filed Date Stamp Here EXPEDITED HEARING NOTICE OF APPEAL
Tennessee Division of Workers' Compensation
Docket#: - - - -- -- - --
www.tn.go v/labor-wfd/wcomp.shtm l
State File #/YR: - - -- - - --
wc.courtclerk@tn.gov
1-800-332-2667 RFA#: _ _ _ _ _ _ _ _____ _
Date of Injury: - - - -- - - - -
SSN: _______ _ ______ __
Employee
Employer and Carrier
Notice
Noticeisg~enthat _ _ _ _ _ _ _~~--~~~~---~~~--------~
[List name(s) of all appealing party(ies) on separate sheet if necessary]
appeals the order(s) of the Court of Workers' Compensation Claims at _ __
-~~~-----~~~~~~~~-to the Workers' Compensation Appeals Board .
[List the date(s) the order(s) was filed in the court clerk's office]
Judge___________________________________________
Statement of the Issues
Provide a short and plain statement of the issues on appeal or basis for relief on appeal:
Additional Information
Type of Case [Check the most appropriate item]
D Temporary disability benefits
D Medical benefits for current injury
D Medical benefits under prior order issued by the Court
List of Parties
Appellant (Requesting Party): _____________ .A t Hearing: DEmployer DEmployee
Address:. _______________________ ______________ ___________
Party's Phone:.____________________________ Email: _________________________
Attorney's Name:________________________________ ___ BPR#: - - - - - - - - - - - -
Attorney's Address:. _ _ _ _ _~~-~~~~----~~---- Phone:
Attorney's City, State & Zip code: _____________________ ___________ _ _ _ __ _
Attorney's Email :_ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ __ _ _ _ __ _ _ _ _ _ _ __
*Attach an additional sheet for each additional Appellant*
LB-1099 rev.4/15 Page 1 of 2 RDA 11082
Employee Name: - - - -- - - -- - - - SF#: _ _ _ _ __ _ _ _ _ DO l: _ __ _ __
Aopellee(s)
Appellee (Opposing Party): _ _ _ _ _ _ _ _.At Hearing: OEmployer DEmployee
Appellee's Address: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Appellee's Phone:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _.Email:_ _ _ _ _ _ __ _ _ _ _ _ __
Attorney's Name:_ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ BPR#: - - - - - - - -
Attorney's Address:._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Phone:
Attorney's City, State & Zip code: - - - -- - - - - - - - - - - - - - - - - - - -- -
Attorney's Email:._ _ _ _ __ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
* Attach an additional sheet for each additional Appellee *
CERTIFICATE OF SERVICE
I, certify that I have forwarded a true and exact copy of this
Expedited Hearing Notice of Appeal by First Class, United States Mail, postage prepaid, to all parties
and/or their attorneys in this case in accordance with Rule 0800-02-22.01(2) of the Tennessee Rules of
Board of Workers' Compensation Appeals on this the day of__, 20_ .
[Signature of appellant or attorney for appellant]
LB-1099 rev.4/1S Page 2 of 2 RDA 11082
.
ll .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: ' ; !•
'
Rent/House Payment $ per month Medical/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