Form 136 - Affidavit of Indigence and Request for Waiver of § 11A(2) Fees

Department of Industrial Accidents (DIA)

This government document is issued by Department of Industrial Accidents (DIA) for use in Massachusetts

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File Details: PDF (178 KB)
Source
https://www.mass.gov/doc/form-136-affidavit-of-indigence-and-request-for-waiver-of-ss-11a2-fees/download?_ga=2.187478184.1854129817.1751542062-2000327536.1747311789&_gl=1*17oobgw*_ga*MjAwMDMyNzUzNi4xNzQ3MzExNzg5*_ga_MCLPEGW7WM*czE3NTE1NDIwNjIkbzY4JGcxJHQxNzUxNTQ2ODcxJGo2MCRsMCRoMA..

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