Form 132 "Affidavit in Support of Employee's Request for Speedy Conference Because of Hardship" - Massachusetts

What Is Form 132?

This is a legal form that was released by the Massachusetts Department of Industrial Accidents - a government authority operating within Massachusetts. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2019;
  • The latest edition provided by the Massachusetts Department of Industrial Accidents;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 132 by clicking the link below or browse more documents and templates provided by the Massachusetts Department of Industrial Accidents.

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Download Form 132 "Affidavit in Support of Employee's Request for Speedy Conference Because of Hardship" - Massachusetts

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FORM 132
The Commonwealth of Massachusetts
DIA Board #
Department of Industrial Accidents – Department 132
(If Known):
Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111-1750
Info. Line (800) 323-3249 Inside Mass. / (857) 321-7470 Outside Mass.
www.mass.gov/dia
AFFIDAVIT IN SUPPORT OF EMPLOYEE’S
REQUEST FOR SPEEDY CONFERENCE BECAUSE
OF HARDSHIP
1. INFORMATION ON EMPLOYEE’S CLAIM
Employee’s Name:__________________________________ Social Security #*: ____________________________
Employee’s Address: _______________________________ Employee’s Telephone #: ______________________
__________________________________________________
DIA Board #:______________________________________ DIA Region: _________________________________
Date of Injury: ____________________________________
Employer: __________________________________
Workers’ Comp. Insurer: ___________________________
2. INFORMATION ON EMPLOYEE’S HOUSEHOLD
A. Names and ages of minor children living with you:
1. _______________________________; 2. _______________________________; 3. _________________________;
4. _______________________________; 5. _______________________________; 6. _________________________;
B. Names of persons over 18 who live with you and who are currently financially dependent on you;
1. _______________________________; 2. _______________________________; 3. _________________________;
_______________
C. Check all applicable boxes - I live with my:
Spouse
Parents
Other
3. CURRENT GROSS WEEKLY INCOME FROM ALL SOURCES:
You
Spouse
Other Source
A. Workers’ Compensation
$_______________
$____________
$____________
B. Unemployment Insurance
$_______________
$____________
$____________
C. Private Disability Insurance
$_______________
$____________
$____________
D. Public Assistance (Welfare, AFDC Payments etc.)
$_______________
$____________
$____________
E. Food Stamps (Gross Value of Weekly Allotment)
$_______________
$____________
$____________
F. Social Security
$_______________
$____________
$____________
G. Dividends
$_______________
$____________
$____________
H. Income from Trusts and Annuities
$_______________
$____________
$____________
I.
Pensions and Retirement Funds
$_______________
$____________
$____________
J.
Alimony and/or Child Support
$_______________
$____________
$____________
K. Contribution/Income from other sources
$_______________
$____________
$____________
L. All other income not set forth above
$_______________
$____________
$____________
M. TOTAL GROSS WEEKLY INCOME (add A thru L) $_______________
$____________
$____________
*Disclosing Social Security Number is voluntary. It will assist in the processing of your request.
Page 1 of 2 - Please complete reverse side.
REPRODUCE AS NEEDED.
Form 132 - Revised 7/2019
FORM 132
The Commonwealth of Massachusetts
DIA Board #
Department of Industrial Accidents – Department 132
(If Known):
Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111-1750
Info. Line (800) 323-3249 Inside Mass. / (857) 321-7470 Outside Mass.
www.mass.gov/dia
AFFIDAVIT IN SUPPORT OF EMPLOYEE’S
REQUEST FOR SPEEDY CONFERENCE BECAUSE
OF HARDSHIP
1. INFORMATION ON EMPLOYEE’S CLAIM
Employee’s Name:__________________________________ Social Security #*: ____________________________
Employee’s Address: _______________________________ Employee’s Telephone #: ______________________
__________________________________________________
DIA Board #:______________________________________ DIA Region: _________________________________
Date of Injury: ____________________________________
Employer: __________________________________
Workers’ Comp. Insurer: ___________________________
2. INFORMATION ON EMPLOYEE’S HOUSEHOLD
A. Names and ages of minor children living with you:
1. _______________________________; 2. _______________________________; 3. _________________________;
4. _______________________________; 5. _______________________________; 6. _________________________;
B. Names of persons over 18 who live with you and who are currently financially dependent on you;
1. _______________________________; 2. _______________________________; 3. _________________________;
_______________
C. Check all applicable boxes - I live with my:
Spouse
Parents
Other
3. CURRENT GROSS WEEKLY INCOME FROM ALL SOURCES:
You
Spouse
Other Source
A. Workers’ Compensation
$_______________
$____________
$____________
B. Unemployment Insurance
$_______________
$____________
$____________
C. Private Disability Insurance
$_______________
$____________
$____________
D. Public Assistance (Welfare, AFDC Payments etc.)
$_______________
$____________
$____________
E. Food Stamps (Gross Value of Weekly Allotment)
$_______________
$____________
$____________
F. Social Security
$_______________
$____________
$____________
G. Dividends
$_______________
$____________
$____________
H. Income from Trusts and Annuities
$_______________
$____________
$____________
I.
Pensions and Retirement Funds
$_______________
$____________
$____________
J.
Alimony and/or Child Support
$_______________
$____________
$____________
K. Contribution/Income from other sources
$_______________
$____________
$____________
L. All other income not set forth above
$_______________
$____________
$____________
M. TOTAL GROSS WEEKLY INCOME (add A thru L) $_______________
$____________
$____________
*Disclosing Social Security Number is voluntary. It will assist in the processing of your request.
Page 1 of 2 - Please complete reverse side.
REPRODUCE AS NEEDED.
Form 132 - Revised 7/2019
Page 2 of 2
4. CURRENT WEEKLY EXPENSES:
A. Rent or Mortgage (Principal, Interest & Taxes)
$___________________________
B. Home Owner’s or Tenant’s Insurance
$___________________________
C. Maintenance and Repair of Dwelling
$___________________________
D. Heat
$___________________________
E. Electricity
$___________________________
F. Telephone
$___________________________
G. Water/Sewer
$___________________________
H. Food
$___________________________
I.
Clothing
$___________________________
J.
Life and Health Insurance Premiums
$___________________________
K. Court Judgment on which you pay regular amount
$___________________________
L. Auto Insurance
$___________________________
M. Auto Payment
$___________________________
N. Child Care
$___________________________
O. Credit Cards
$___________________________
P. Other (explain) ____________________________
$___________________________
TOTAL WEEKLY EXPENSES
$___________________________
5. PERSONAL PROPERTY/LIQUID ASSETS
A. IRA, Keogh
$___________________________
B. Stocks, Bonds
$___________________________
C. Life Insurance: Present Cash Value
$___________________________
D. Savings & Checking Accounts, Money Markets, CD’s
$___________________________
E. Automobiles
1.
Fair Market Value $_______________ - Loan $_______________ = Equity $_______________
2.
Fair Market Value $_______________ - Loan $_______________ = Equity $_______________
F. Other Personal Property
$___________________________
TOTAL PERSONAL PROPERTY/LIQUID ASSETS
$___________________________
I HEREBY CERTIFY UNDER THE PAINS AND PENALTIES OF PERJURY THAT THE
ABOVE INFORMATION IS TRUE AND COMPLETE.
Signed: ___________________________________________
Date (mm/dd/yyyy): ________________________________
Page of 2