The opinion
FILED
Sep 07, 2018
10:58 AM(CT)
TENNESSEE COURT OF
WORKERS' COMPENSATION
CLAIMS
TENNESSEE BUREAU OF WORKERS’ COMPENSATION
IN THE COURT OF WORKERS’ COMPENSATION CLAIMS
AT MURFREESBORO
DOUGLAS KRUPLA, ) Docket No. 2018-05-0267
EMPLOYEE, )
v. )
)
EAGLE TRANSPORT CORP. ) State File No. 62286-2017
EMPLOYER, )
and )
)
GREAT WEST CAS. CO., ) Judge Dale Tipps
EXPEDITED HEARING ORDER GRANTING BENEFITS
This matter came before the Court on August 29, 2018, for an Expedited Hearing.
The present focus of this case is whether Mr. Krupla is entitled to the total knee
replacement surgery ordered by Dr. Michael Jordan, his authorized treating physician
(ATP). The central legal issue is whether he is likely to establish at a hearing on the
merits that his need for total knee replacement resulted from a compensable aggravation
of a preexisting condition. For the reasons below, the Court finds that Mr. Krupla would
likely meet this burden and orders Eagle Transportation to provide the recommended
surgery.
History of Claim
Mr. Krupla worked for Eagle Transportation as a truck driver. He testified that his
job required significant physical capabilities, including climbing and heavy lifting, which
he performed with no problems before his work accident. Although he had some prior
issues and treatment involving his left knee, those had resolved, and he was having no
pain or difficulty with his knee until August 15, 2017.
On that date, Mr. Krupla attempted to step up into his truck when the step gave
way, catching his boot and causing his left knee to bend and pop. He fell to the ground,
suffering multiple injuries. Eagle accepted the claim and provided medical and
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temporary disability benefits.
Medical Treatment
Mr. Krupla’s medical treatment began at St. Thomas Rutherford Hospital on the
day of the accident. Emergency room records show that he reported pain in his thoracic
spine, left knee, and right groin.
After his discharge from the ER, Eagle provided a panel of physicians, and Mr.
Krupla selected Concentra. His treatment there included several visits for pain in his
back, groin, and left knee. He testified that, even though Concentra’s records did not
always reflect it, he experienced increasing pain in his left knee throughout the course of
his treatment. Mr. Krupla felt that the Concentra doctors were more concerned about his
back until he insisted they address his knee problem.
Concentra’s records show Mr. Krupla’s first visit was August 17, when he saw Dr.
William Dutton. Dr. Dutton noted complaints of pain in the right shoulder, back, left
knee, and groin. He also noted, “States left knee and right hip feel ok now.” Along with
other injuries, Dr. Dutton assessed “contusion of left knee, initial encounter.”
Mr. Krupla returned to Concentra and saw Dr. Frank Thomas on August 25.
Regarding the left knee, Dr. Thomas noted, “The symptoms are improving.”
Two subsequent visits to Concentra on September 5 and September 7 focused
primarily on Mr. Krupla’s back pain. The records from those visits make no specific
mention of ongoing knee pain but do refer to unspecified “joint pain.” These
examinations led to an orthopedic specialist referral for thoracic spine pain.
Mr. Krupla returned to Concentra on October 31 for a recheck of his knee injury.
In the History of Present Illness section, Dr. Thomas noted in part:
The symptoms are unchanged. Symptoms are located in the left knee and
left medial knee. The symptoms occur frequently. The patient describes
the pain as sharp and burning. The severity of the pain is moderate. . . .
He continues to limp and have pain medial knee and swells at intervals. It
has not improved since the original injury.
Dr. Thomas also found tenderness over the medial joint line and a positive medial
McMurray test. He noted “roughly 25% of anticipated healing has taken place” and
referred Mr. Krupla for an MRI and orthopedic specialist.
Dr. Jordan, an orthopedic surgeon, saw Mr. Krupla a few days later. An MRI
showed a medial meniscus tear and degenerative joint disease. After treating Mr. Krupla
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for several weeks, Dr. Jordan recommended an arthroscopic partial medial meniscectomy
stating, “I do think the work injury that he sustained that he has described to me is
responsible for the surgery that is being proposed.”
Utilization Review denied the recommended arthroscopic procedure. Upon
appeal, the Bureau’s Assistant Medical Director upheld the denial and stated, “The
demographics and the degree of arthritis on MRI would be consistent with ODG criteria
for arthroplasty, but is not congruent with indications for meniscectomy or
microfracture.” After receiving that Bureau decision, Dr. Jordan recommended
arthroplasty (total knee replacement).
Causation Questionnaires
While treating Mr. Krupla, Dr. Jordan responded to several written questionnaires
regarding causation. The first questionnaire, sent by the carrier, asked the doctor to
address causation based on the following facts: 1) that Mr. Krupla said in a recorded
statement three days after his accident that his knee was sore, but he didn’t think it was
injured; and 2) his next complaints of knee pain were two months later. Dr. Jordan
prefaced his responses by stating, “This sequence of events would not support current
treatment.” The first question asked which percent of the current complaints and need for
treatment were related to “a prior meniscus injury that the claimant reports happened
roughly 2 years ago.” Dr. Jordan responded that he was “unable to tell – in our computer
seems like it was the right knee.” He went on to say that he was unable to tell which
percent of the current complaints and need for treatment were related to the August 15
work accident or to degeneration, although he stated, “WC is not responsible for the DJD
– just the contusion.”
The carrier’s second questionnaire asked Dr. Jordan to assign causation
percentages to his meniscectomy recommendation. He stated that the partial medial
meniscectomy was 100% related to the contusion from the work accident.
After Dr. Jordan changed his recommendation to total knee replacement, Mr.
Krupla’s attorney sent him another questionnaire. The questions and Dr. Jordan’s
responses are as follows:
1) Is it your opinion . . . that Mr. Krupla’s work-related knee injury
resulted in an aggravation of any pre-existing or degenerative knee
condition necessitating the need for medical treatment? YES
2) If yes, did this aggravation arise primarily out of the August 15, 2017
work injury? YES
3) Have Mr. Krupla’s symptoms returned to their pre-injury baseline
level? NO
4) What further medical treatment do you believe to be reasonable and
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medically necessary in order to treat this injury or aggravation? A/A
KNEE OR TKR
A fourth causation questionnaire came from Mr. Krupla’s independent medical
evaluation (IME) with Dr. David West, performed at Eagle’s request. Dr. West
confirmed that Mr. Krupla had a knee contusion, but he felt there was no objective
aggravation to the preexisting arthritis. He agreed that a knee replacement was an option,
but he did not feel Mr. Krupla’s fall caused the need for the procedure. He concluded,
“[I]t is my opinion that the patient’s need for treatment is due to his underlying ordinary
progression of life and osteoarthritis and not directly related, certainly less than 51%
related, to the injury of fall to the left knee.”
Dr. West’s Deposition
Dr. West testified that there was no way to determine how long Mr. Krupla’s
meniscus had been torn, but “it’s easy to say that he had very bad arthritis in three
compartments of his knee” before the workplace accident. He observed that the early
Concentra notes reflected improvement in the knee, and the September visit notes made
no mention of knee pain. From this, he concluded that Mr. Krupla had returned to his
pre-fall baseline. Dr. West stated, “[T]he advanced osteoarthritis is the primary cause in
the need for knee replacement. And of course pain is a very big deciding factor for knee
replacements, but if you base a percentage again as related to this accident, I’d say it’s
very small.” He felt the fall caused no structural change to the knee and characterized
Mr. Krupla’s condition as “a temporary exacerbation of an underlying condition.”
On cross-examination, Dr. West testified that he never discussed Mr. Krupla’s
medical records with him or asked him whether his symptoms ever resolved. Shown the
October 31 Concentra note, he admitted that if correct, the note would mean that Mr.
Krupla’s knee had not returned to baseline. He also admitted that, if Mr. Krupla had
continuing pain between the injury and the time Concentra ordered the MRI, he would
characterize the exacerbation as chronic.
Dr. Jordan’s Deposition
Eagle’s counsel asked Dr. Jordan to review Mr. Krupla’s Concentra records from
August 17 through September 7 and then asked, “[A]ssuming he had a resolution of pain
from August 25th through the date you saw him on November 8th, 2017, is it your opinion
that he returned to baseline condition?” Dr. Jordan responded, “If his baseline condition
was no pain and he was having no pain as of two days post-injury, through the several
visits that we looked at, I would say the answer to that is yes.” He went on to testify that,
based on these assumptions, his opinion may have changed to, “in fact everything going
on in his knee may be related more to DJD than to the injury.” Further, based on the
August and September Concentra visits, he felt that the aggravation of Mr. Krupla’s
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preexisting arthritis was temporary.
On cross-examination, Dr. Jordan acknowledged it was difficult to tell from the
August Concentra records whether Mr. Krupla actually complained of knee pain. Upon
being shown the October 31 record, he agreed it indicated Mr. Krupla was having knee
pain throughout the course of his treatment at Concentra. Assuming Mr. Krupla had no
symptoms or knee pain before the work accident and had consistent pain afterwards, Dr.
Jordan felt that his recommended treatment was necessary due to an aggravation of a
preexisting condition. Again, asked to assume that Mr. Krupla’s symptoms did not
resolve after the accident, Dr. Jordan reaffirmed the opinions in his response to the
questionnaire from Mr. Krupla’s attorney.
Mr. Krupla requested that the Court order Eagle to provide additional medical
treatment, specifically the total knee replacement recommended by Dr. Jordan.
Eagle countered that the Court should deny the surgical procedure because Mr.
Kupla failed to establish he would likely prevail at a hearing on the merits in proving his
work injury primarily caused his current need for treatment. Specifically, it argued that
Mr, Krupla suffered a temporary, non-compensable aggravation of his preexisting joint
disease.
Findings of Fact and Conclusions of Law
Mr. Krupla 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); McCord v. Advantage Human
Resourcing, 2015 TN Wrk. Comp. App. Bd. LEXIS 6, at *7-8, 9 (Mar. 27, 2015). To
qualify for medical benefits at an interlocutory hearing, an injured worker who alleges an
aggravation of a pre-existing condition must offer evidence that the aggravation arose
primarily out of and in the course and scope of employment. That is, Mr. Krupla must
come forward with sufficient evidence from which the Court can determine that he would
likely establish, to a reasonable degree of medical certainty, that the work accident
contributed more than fifty percent in causing the aggravation, considering all causes.
Tenn. Code Ann. § 50-6-102(14); Miller v. Lowe’s Home Centers, Inc., 2015 TN Wrk.
Comp. App. Bd. LEXIS 40, at *18 (Oct. 21, 2015).
In order to establish causation, Mr. Krupla relies on the ATP, Dr. Jordan, whose
opinion is presumed correct. See Tenn. Code Ann. § 50-6-102(14)(E). One of the
difficulties faced by the Court is that Dr. Jordan gave apparently conflicting causation
opinions.1 This conflict is resolvable, however. At its essence, Dr. Jordan’s opinion
1
The Court finds it unnecessary to address the first two questionnaires completed by Dr. Jordan, as they
5
depends on one factual issue: Did Mr. Krupla have continuing pain from the date of his
accident until Concentra ordered an MRI and made an orthopedic referral on October 31?
If so, Dr. Jordan would say the work injury made the surgery necessary because it
aggravated a preexisting condition. If not, he would view the aggravation as temporary
and, therefore, not the cause of his current need for surgery.
Mr. Krupla testified about this issue. Specifically, he said that he had no pain in
his left knee or any limitations at work or other activities before his work injury. After
the accident, he experienced increasing pain in his left knee throughout the course of his
treatment at Concentra but had difficulty getting the doctors to address his knee injury.
The Court notes that Mr. Krupla appeared steady, forthcoming, reasonable, and honest,
which characteristics, according to the Tennessee Supreme Court, are indicia of
reliability. See Kelly v. Kelly, 445 S.W.3d 685, 694-695 (Tenn. 2014). His testimony is
also supported by the October 31 Concentra record, which states, “He continues to limp
and have pain medial knee and swells at intervals. It has not improved since the original
injury.” Further, Eagle provided no testimony from the nurse case manager or any
Concentra personnel to rebut Mr. Krupla’s characterization of his knee problems. The
Court therefore finds Mr. Krupla to be credible and accepts his description of progressive
knee pain through the period of his Concentra treatment.
Eagle contends that the Concentra records show that Mr. Krupla’s knee pain
subsided within a couple of weeks after the accident. The Court recognizes that the
medical records contain a number of somewhat inconsistent or incomplete descriptions of
Mr. Krupla’s symptoms. However, medical records are rarely infallible. Further, the
records do not show that Mr. Krupla repeatedly changed his description of the accident or
the cause of his knee pain. Instead, his primary complaints simply varied from visit to
visit with no explanation or emphasis. Mr. Krupla attributed this to the medical providers
continued focus on injuries to body parts other than his knee. Other causes for these
variations may be attributable to Concentra’s record-keeping or the fact that more than
one doctor saw Mr. Krupla during his treatment there. There is no indication that these
explanations are less likely than an actual lack of knee symptoms experienced by Mr.
Krupla, especially in view of the final Concentra record that stated that his knee condition
“is unchanged.” Without testimony from the Concentra doctors or some other evidence,
the Court is unwilling to assume that Mr. Krupla had no knee symptoms, based solely on
the relative lack of recorded knee symptoms in a few of the medical records. Further, to
the extent that Eagle suggested that Mr. Krupla must have suffered some sort of
intervening injury before October 31, it presented no proof supporting this contention.
Having found that Mr. Krupla suffered relatively constant knee pain through
October 31, the Court accepts Dr. Jordan’s opinion that Mr. Krupla’s work injury was the
both failed to ask his opinion regarding total knee replacement or whether it was made necessary by an
aggravation of Mr. Krupla’s preexisting condition.
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primary cause of the aggravation of his degenerative knee condition. As noted above,
this opinion is entitled to a presumption of correctness.
Eagle contends that Dr. West’s testimony is sufficient to overcome the
presumption. To make this determination, the Court must compare the opinions of Dr.
West and Dr. Jordan.
When the medical testimony differs, the trial judge must obviously choose
which view to believe. In doing so, he is allowed, among other things, to
consider the qualifications of the experts, the circumstances of their
examination, the information available to them, and the evaluation of the
importance of that information by other experts.
Orman v. Williams Sonoma, Inc., 803 S.W.2d 672, 676 (Tenn. 1991).
Applying the first of these factors, the Court notes that both physicians are
orthopedic surgeons. Although both of their deposition transcripts indicate that their
curriculum vitae were exhibits to their testimony, neither of the transcripts filed with the
court included those exhibits. In the absence of any information concerning their
respective qualifications, the Court cannot find any determinative differences between the
doctors.
As to the other factors, the circumstances of the respective examinations are
different, in that Mr. Krupla was an established patient with Dr. Jordan, while he only
saw Dr. West once. However, it appears that the information available to the doctors was
comparable. Overall, the Court finds little difference between the doctors, other than
their actual conclusions. Thus, Dr. West’s testimony must be sufficient on its own to
overcome the presumption in favor of Dr. Jordan.
The primary problem with Dr. West’s opinion is that he predicated it on the
assumption that Mr. Krupla’s knee condition resolved within a couple of weeks and
“returned to baseline.” However, he based that assumption solely on his review of the
first few Concentra notes. Dr. West admitted he did not discuss Mr. Krupla’s medical
records with him or ask him whether his symptoms ever resolved. Further, he conceded
that if the October 31 note were correct, that would mean Mr. Krupla’s knee did not
return to its baseline symptoms and that the exacerbation of his osteoarthritis was
chronic. As the Court has already determined that Mr. Krupla’s knee pain never fully
subsided, this testimony not only fails to overcome the presumption of correctness, but it
actually supports Dr. Jordan’s opinion.
After careful consideration, the Court finds that Dr. West’s analysis and
conclusions are insufficient to overcome the presumption of correctness of Dr. Jordan’s
causation opinion. Mr. Krupla therefore appears likely to prevail at a hearing on the
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merits in proving that he suffered an aggravation, arising primarily out of and in the
course and scope of employment, of his preexisting degenerative joint disease.
Therefore, the Court concludes Eagle must provide the knee replacement surgery
recommended by Dr. Jordan.
IT IS, THEREFORE, ORDERED as follows:
1. Eagle Transport Corporation shall provide Mr. Krupla with medical treatment
made reasonably necessary by the August 15, 2017 injury in accordance with
Tennessee Code Annotated section 50-6-204, including the knee replacement
surgery recommended by Dr. Jordan.
2. This matter is set for a Scheduling Hearing on October 31, 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.
3. 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.
4. For questions regarding compliance, please contact the Workers’ Compensation
Compliance Unit via email at WCCompliance.Program@tn.gov.
ENTERED this the 7th day of September, 2018.
_____________________________________
Judge Dale Tipps
Court of Workers’ Compensation Claims
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APPENDIX
Exhibits:
1. Affidavit of Douglas Krupla
2. Indexed medical records
3. Dr. West’s IME report
4. Deposition transcript of Dr. David West
5. Deposition Transcript of Dr. Michael Jordan
6. Transcript of Douglas Krupla’s recorded statement (Identification Only)
Technical record:
1. Petition for Benefit Determination
2. Request for Expedited Hearing
3. Dispute Certification Notice
4. Employer’s Pre-Hearing Brief
5. Employee’s Brief in Support of Request for Expedited Hearing
6. Employee’s Supplemental Brief in Support of 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 7th day of
September, 2018.
Name Certified Fax Email Service sent to:
Michael Fisher, X mfisher@ddzlaw.com
Employee’s Attorney
Marianna Joblonski, X mjablonski@wimberlylawson.com
Employer’s Attorney
_____________________________________
Penny Shrum, Clerk of Court
Court of Workers’ Compensation Claims
WC.CourtClerk@tn.gov
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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