The opinion
TENNESSEE BUREAU OF WORKERS' COMPENSATION
IN THE COURT OF WORKERS' COMPENSATION CLAIMS
AT COOKEVILLE
Paul Adcock, ) Docket No. 2017-04-0046
Employee, )
v. )
Robert L. Chaffin ) State File No. 29534-2015
Employer, )
And )
Auto Owners Ins. Co., ) Judge Robert Durham
Insurance Carrier. )
COMPENSATION HEARING ORDER
This case came before the Court on August 1, 2018, for a Compensation Hearing.
The only issues were whether Mr. Adcock was entitled to additional permanent disability
benefits for his previously settled claim, and if so, in which amount. For the reasons
below, the Court holds Mr. Adcock is entitled to increased permanent disability benefits
under Tennessee Code Annotated section 50-6-207(3)(B) but not extraordinary relief.
History of Claim
On February 4, 2015, Mr. Adcock suffered a work-related cervical spine injury
while working for Chaffin. Dr. Leonardo Rodriguez-Cruz eventually performed a
cervical fusion. After Mr. Adcock reached maximum medical improvement (MMI), Dr.
Rodriguez-Cruz assigned a 12% whole-body impairment and endorsed the following
physical permanent restrictions recommended through a functional capacity evaluation:
occasional carrying up to 25 pounds; lifting up to 25 pounds from floor to shoulder and
15 pounds from shoulder to overhead; 15 pounds out from body; unilateral lift, maneuver
and carry, RUE-15 pounds, LUE-20 pounds; push/pull and force-RUE alone-65
pounds.
The parties settled Mr. Adcock's claim on March 16, 2017, for 12% permanent
disability at a compensation rate of $260.01. Mr. Adcock's initial compensation period
expired on October 26, 2017. Between the date of injury and October 26, Chaffin went
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out of business. Consequently, Mr. Adcock never returned to work for Chaffin nor
attempted to work elsewhere.
After his initial compensation period expired, Mr. Adcock filed a petitiOn for
additional permanent disability under either Tennessee Code Annotated section 50-6-
207(3)(B) (increased benefits) and/or Tennessee Code Annotated section 50-6-242(a)(2)
(extraordinary relief). He attached a certification form signed by Dr. Rodriguez-Cruz,
who certified Mr. Adcock could not return to his pre-injury occupation due to the
permanent restrictions caused by his work-related injury. Before the compensation
hearing, the parties submitted a joint statement agreeing that the only issue concerned
increased benefits. It stated that if 50-6-207(3)(B) applies, the "resulting award" would
be based on Mr. Adcock's age and his failure to return to pre-injury wages.
Chaffin introduced Dr. Rodriguez-Cruz's deposition at the hearing. The doctor
reiterated that the permanent work restrictions were appropriate for Mr. Adcock's
continuing symptoms due to his work injury. However, he further stated that the primary
limitation from the injury was continued, palpable, right shoulder tenderness and loss of
strength in the right triceps muscle. He also stated Mr. Adcock suffered minimal loss of
neck motion and did not complain of numbness. Mr. Adcock's grip strength was
unimpaired. Dr. Rodriguez-Cruz did not testify about any significant risk of re-injury to
the cervical spine or the need for additional treatment.
As to Mr. Adcock's ability to return to work, Dr. Rodriguez-Cruz stated he signed
the certification about Mr. Adcock's employment as a tractor-trailer driver. He
understood the job frequently required more strenuous activity than simply driving, such
as hooking and unhooking trailers, doing inspections and making repairs. However, he
believed Mr. Adcock could continue driving, including driving trucks with manual
transmissions, so long as the gearshift was not unduly difficult to operate. He further
testified he did not believe Mr. Adcock was totally disabled but was ')ust less than" an
able-bodied person. He did not intend for his certification to infer otherwise.
Mr. Adcock testified that he continues to have problems with pain and weakness
in his neck and right arm. He believes these symptoms would interfere with his ability to
drive a tractor-trailer, specifically: hooking and unhooking trailers; doing inspections,
which includes bending, reaching, and lifting the hood; and moving his spare tire.
Mr. Adcock testified that he is not comfortable driving for any significant time.
He performs some household chores, such as taking out the trash, grocery shopping,
dusting, and gathering the laundry. He is currently taking 30 milligrams of Oxycodone
four times per day for neck and right arm pain. He still has his commercial drivers'
license, but the Department of Transportation notified him that he must undergo a
medical examination as to his fitness to drive a truck or he will lose it. He testified that
the injury caused him to "put everything on hold," given that his expectation of working
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for another ten or twelve years will not be realized.
Beyond working as a truck driver, Mr. Adcock's employment history primarily
consisted of warehouse work, factory work as a crane operator, and housekeeping for a
small hospital. He does not believe that he could perform any of his previous jobs given
his limitations. He has a high school education and a certification from truck driving
school. Mr. Adcock admitted that he has not looked for work since his injury because he
does not believe he could return to any of his former employments. Instead, he focused
his efforts on obtaining social security disability benefits.
In addition to Mr. Adcock, Michelle Weiss, a vocational rehabilitation counselor
retained by Chaffin, testified. Ms. Weiss reviewed Mr. Adcock's medical records and
interviewed him regarding his vocational history. She also tested his ability to read and
do math. She determined that Mr. Adcock's reading comprehension was average to
above average for someone at his age and education level. His math skills fell somewhat
below average, although he could multiply three-digit numbers, divide, and add or
subtract multiple numbers.
Ms. Weiss conceded that, given his physical restrictions, Mr. Adcock could not
return to work as a "heavy" truck driver, which includes tractor-trailers. However, there
were many other jobs that fall under the occupation "driver," which she felt Mr. Adcock
could do, such as driving vans, pick-up trucks, light-box trucks, etc. In addition, Mr.
Adcock could perform other jobs outside of driving that fall within his restrictions,
although he might lose some income compared to his pre-injury wages. Applying these
factors to Mr. Adcock's regional job market, Ms. Weiss determined that he sustained a
35% vocational impairment from his work injury.
After the hearing, the Court noted the Petition for Benefit Determination described
Chaffin's address as "Gainesboro" and indicates it was in Jackson County. But the Court
found no evidence in the record to that effect. 1 Thus, the Court decided sue sponte to
reopen the hearing on August 16, 2018, to allow evidence regarding Mr. Adcock's place
of employment at the time of the injury and the possible application of the unemployment
multiplier in 50-6-207(3)(B).
Findings of Fact and Conclusions of Law
Mr. Adcock has the burden of proof on all essential elements of his workers'
compensation claim. Scott v. Integrity Staffing Solutions, 2015 TN Wrk. Comp. App. Bd.
LEXIS 24, at *6 (Aug. 18, 20 15). "[A]t a compensation hearing where the injured
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The pre-hearing statement indicated that either party "may introduce" any documents previously filed
with the Bureau, which would include the First Report of Injury and its description of Chaffin's address,
as an exhibit to the hearing. However, neither party did so.
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employee has arrived at a trial on the merits, the employee must establish by a
preponderance of the evidence that he or she is, in fact, entitled to the requested benefits."
Willis v. All Staff, 2015 TN Wrk. Comp. App. Bd. LEXIS 42, at *18 (Nov. 9, 2015).
Here, the parties agreed that Mr. Adcock sustained a compensable work injury. The only
issues involve whether he is entitled to additional permanent disability benefits and if so
how much.
Chaffin argues Mr. Adcock is not entitled to any additional permanent disability
benefits because his failure to seek post-injury employment means he did not make a
meaningful effort to return to work as required by the Workers Compensation Law. The
"meaningful return to work" doctrine holds that whether the employee is entitled to
additional benefits is governed by the reasonableness of the employer's post-injury job
offer and the reasonableness of the employee's refusal to perform the job. See Dennis v.
Polymer Components, 2016 TN Wrk. Comp. App. Bd., LEXIS 47, at *10 (Sept. 27,
20 16). Chaffin maintains the doctrine is particularly relevant given that, with the 2014
reform, the Court must now consider whether Mr. Adcock returned to any employment
that paid as much or more than his pre-injury job, and not just whether the pre-injury
employer made such a job available to the employee. Tenn. Code Ann. 50-6-207(3)(B).
To support its argument, Chaffin cited Batey v. Deliver This, Inc., 2018 TN Wrk.
Comp. App. Bd., LEXIS 2, at *15, 16 (Feb. 6, 2018). In Batey, the Workers'
Compensation Appeals Board held that the phrase "pre-injury occupation" in section 50-
6-242(a)(2) means more than just the employee's ability to perform the job he had before
his injury but encompasses a class of jobs that require similar duties. The Appeals Board
referred to section 50-6-207(3)(B), which states that an employee who returns to a job
with any employer at or above pre-injury wages is not entitled to increased benefits. The
Board found that it would be "incongruous" for that statute to consider the employee's
return to work for any employer in determining the right to increased benefits, while
allowing an employee to show only that he could not return to the pre-injury job to try to
prove the claim was "extraordinary" under section 50-6-242. !d.
Mr. Adcock responds that the "meaningful return to work" doctrine no longer
applies. Section 50-6-207(3)(D) sets out specific examples of when an employee who
does not return to work is denied additional benefits: resignation or retirement,
misconduct, or a general workforce wage reduction. Mr. Adcock observes that the
reasons do not include whether employees were "reasonable" in their efforts to find work
within their restrictions in the general labor market, which the legislature could have done
had that been their intent. Further, he argues that to allow this type of restriction would
encourage employers to terminate injured employees and open the floodgates for
contested claims for increased benefits.
In weighing these arguments, the Court notes that the Appeals Board considered
the "meaningful return to work" doctrine in determining whether an employee is entitled
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to additional disability benefits under post-reform law. Dennis, at *10. However, the
Court knows of no authority where the Appeals Board or the Supreme Court considered
the reasonableness of the employee's efforts to find work in the general labor market
when deciding whether to award increased benefits under section 50-6-207(3)(B). The
Court does not consider the Appeals Board's decision in Batey to extend the "meaningful
return to work" doctrine beyond the pre-injury employer/employee relationship. Doing
so would provide the pre-injury employer with little if any incentive under workers'
compensation law to return the injured employee to work. The parties stipulated that
Chaffin did not offer a post-injury job to Mr. Adcock and that he was not working when
the initial compensation period expired. Thus, the Court holds that Mr. Adcock is
entitled to increased benefits under section 50-6-207(3)(B) in the stipulated amount of
$8,705.13, given that he did not return to work and is over the age offorty. 2
However, the question remains whether Mr. Adcock is entitled to more permanent
disability benefits under Tennessee Code Annotated section 50-6-242. This statute
provides that in "extraordinary" cases the employee may receive up to 275 weeks of
benefits ifthe employee satisfies the elements of section 50-6-207(3) and: (1) has at least
a 10% impairment rating; (2) the authorized doctor signed a form certifying that the
employee could not return to the pre-injury occupation due to restrictions related to the
work injury; (3) the employee is not earning at least 70% ofthe pre-injury wage; and, (4)
the employee has proven by clear and convincing evidence that limiting recovery to
section 50-6-207(3)(B) would be "inequitable in light of the totality of the
circumstances."
Here, it is undisputed that Dr. Rodriguez-Cruz gave Mr. Adcock an impairment
rating of 12%. He also certified on the proper form that Mr. Adcock could not return to
his pre-injury occupation. While Chaffin argues that, pursuant to Batey, "pre-injury
occupation" should include any form of commercial driving as opposed to only driving
tractor-trailers, the Court holds that definition is overbroad and will not extend it beyond
whether Mr. Adcock is able to drive tractor-trailers.
Further, as with the Court's holding regarding the applicability of section 50-6-
207, the Court declines to consider the reasonableness of Mr. Adcock's failure to seek
employment in the general labor market in determining whether he is earning at least
70% of his pre-injury wages. Instead, the Court gives that part of the statute its obvious
2
Although the Court re-opened the evidence as to the issue of whether the factor regarding
unemployment applied, neither party presented any evidence as to where Mr. Adcock was employed by
the employer at the time ofthe injury. Although Mr. Adcock referred to the First Report of Injury listing
Chaffin's address as Gainesboro, the First Report was never made an exhibit at the original hearing or
when the Court re-opened the evidence. Further, Chaffin's counsel indicated that Mr. Adcock was
actually injured in Anderson County, although no proof was provided as to this assertion, either. Thus,
the Court is not in a position to decide whether it is bound by the parties' stipulations or, if not, whether
Mr. Adcock would be entitled to additional benefits under section 50-6-207(3)(B)(iii).
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meaning and holds Mr. Chaffin met it as well, since the parties agreed that Mr. Adcock
has not worked since his accident. Thus, the Court holds Mr. Adcock met the first three
elements listed above.
However, the statute indicates that, in addition to those elements, the employee
must also prove by "clear and convincing evidence" that it would be "inequitable in light
of the totality ofthe circumstances" to limit the employee's benefits to section 50-6-207.
Clear and convincing evidence is a higher standard than the preponderance of the
evidence, and the Court is obligated to look at all the circumstances to determine if Mr.
Adcock met this standard to establish the inequities of not allowing him additional
benefits.
In support of Mr. Adcock's position are these undisputed facts. He sustained a
work-related cervical spine injury that caused permanent pain in his neck and right arm as
well as demonstrable weakness in his right triceps. These conditions led to permanent
restrictions that made it inadvisable for Mr. Adcock to return to work as a tractor-trailer
driver. Further, Chaffin's vocational expert assessed Mr. Adcock's vocational
impairment at 35%.
But, when considering the "totality of the circumstances" the Court finds that Mr.
Adcock's admitted lack of effort in obtaining post-injury employment weighs against
him. By failing to even try to find work because he believed he could not perform any of
his former employments and instead focusing on receiving social security disability, Mr.
Adcock made it difficult to determine his employability. See, Duignan v. Stowers
Machinery, Corp., 2018 TN Wrk. Comp. App. Bd, LEXIS 25 AT *11, 12 (May 29,
20 18)( efforts to find work in the general labor market to be considered when determining
the issue of permanent total disability). Further, Dr. Rodriguez-Cruz testified that any
cervical loss of motion was negligible and Mr. Adcock's only physical limitation to
employment due to the injury was some loss of strength in his right arm. Mr. Adcock has
a high school education and appears capable of continued learning as evidenced by his
achievement test scores. His testimony about his post-injury limitations primarily
concerned his inability to drive a tractor-trailer. His chief concern regarding his
condition was that his plans had to be postponed due to financial uncertainty.
Weighing all these circumstances, the Court holds that Mr. Adcock failed to prove
by clear and convincing evidence the inequity of limiting his additional permanent
disability benefits to those awarded under section 50-6-207.
IT IS, THEREFORE, ORDERED as follows:
1. Mr. Adcock's vocational disability is 19.44% to the body as a whole, which
equates to $22,745.67 at the stipulated compensation rate of $290.00. After
applying the credit for the original award, Chaffin shall pay $8,705.13 in a lump
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sum from which Mr. Adcock's counsel is awarded 20% as attorney's fees.
2. Chaffin shall continue to provide Mr. Adcock with medical treatment made
reasonably necessary by his February 4, 2015 work injury with Dr. Rodriguez-
Cruz as his authorized physician.
3. The $150.00 filing fee is taxed to Chaffin under Rule 0800-02-21-.07 of the
Tennessee Compilation Rules and Regulations. Chaffin shall also reimburse Mr.
Adcock for reasonable litigation expenses, including but not limited to, court
reporter fees and deposition expenses.
4. Chaffin shall prepare and file a Statistical Data Form within ten business days of
the date of entry of this Order.
5. Absent an appeal, this order shall become final in thirty days.
ENTERED AUGUST 29, 2018.
Court of Workers' Compensation Claims
APPENDIX
.Exhibits:
1. Michelle Weiss's Vocational Report
2. Dr. Rodriguez-Cruz's deposition
3. Dr. Rodriguez-Cruz's Physician Certification Form
4. Michelle Weiss's curriculum vitae
Technical Record:
1. Scheduling Hearing Order
2. Motion to Compel Discovery
3. Response to Motion to Compel Discovery
4. Order Compelling Discovery
5. Joint Pre-Compensation Hearing Statement
6. Brief of Paul Adcock
7. Chaffin Trucking's Brief
8. Chaffin Trucking's Witness and Exhibit List
9. Chaffin Trucking's Notice of Filing Trial Exhibits
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10. Mr. Adcock's Witness List
11. Petition for Benefit Determination
12. Dispute Certification Notice
13. Order Reopening Evidence
14. Chaffin Trucking's Briefwith attachments
15. Mr. Adcock's Briefwith attachments
CERTIFICATE OF SERVICE
I hereby certify that a true and correct copy of the Compensation Hearing Order
Granting Benefits was sent to the following recipients by the following methods of
service on August 29, 2018.
Name Certified Fax Email Service sent to:
Andrea Mel off X ameloff@ddzlaw.com
mpastore@ddzlaw .com
Michael Haynie X mhaxnie@manierherod.com
mgrimmig@manierherod.com
& »vlj#-'
Penn~m, Court Clerk
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II
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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.
Filed Date Stamp Here COMPENSATION HEARING NOTICE OF APPEAL Docket#: ___________________
Tennessee Division of Workers' Compensation
www.tn .gov/labor-wfd/wcomp.shtml State File #/YR: - - - - - - - - - - - - -
wc.courtclerk@tn .gov
1-800-332-2667 RFA#: ____________________
Date of Injury: - - ------------
SSN: _____________________
Employee
Employer and Carrier
Notice
Notice is given that ---------------------------------------------------
[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 _____
---------------------- - -- - - - t o 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 :
List of Parties
Appellant (Requesting Party): _______________ .At Hearing: 0Employer0Employee
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-1103 rev. 4/15 Page 1 of 2 RDA 11082
Employee Name: -- - - - - - - - - - - SF#: _ _ _ _ _ _ _ _ _ _ DOl: _ _ _ _ __
Appellee(s)
Appellee (Opposing Party): ,_ _ _ _ _ _ __ At Hearing:OEmployer[]Employee
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
Compensation 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) ofthe Tennessee Rules of
Board of Workers' Compensation Appeals on this the day o f _ , 20_.
[Signature of appellant or attorney for appellant]
Attention: This form should only be used when filing an appeal to the Workers' Compensation Appeals
Board. If you wish to appeal a case to the Tennessee Supreme Court, please utilize the form provided by
the Court which can be found on their website at the following address:
http://www.tncourts.gov/sites/defau lt/files/docs/notice of appeal - civil or criminal.pdf
LB-1103 rev. 4/15 Page 2 of 2 RDA 11082
II I.
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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