FORM 112A
The Commonwealth of Massachusetts
Department of Industrial Accidents – Department 112A
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
DIA Use Only
AFFIDAVIT IN SUPPORT OF REQUEST FOR WAIVER
OF FILING FEE UNDER §11C
Please provide DIA Board Number: ___________________________
Pursuant to General Laws c. 152, § 11C, the applicant, ____________________________________
(Print Name of Applicant)
swears (or affirms) as follows:
1. Applicant is indigent in that he/she is a person unable to pay the filling fee mandated by § 11C,
or is unable to do so without depriving himself or his dependents of the necessities of life,
including food, shelter and clothing.
2. In support of this affidavit, the applicant submits the following information:
(a) Address of Applicant: ____________________________________________________
(b) Date of Birth: ___________________________________________________________
(c) Highest grade attended in school: ___________________________________________
(d) Special Training: ________________________________________________________
(e) List any physical or mental disabilities: ______________________________________
(f) Marital status: __________________________________________________________
(g) Number of dependents (if applicable): _______________________________________
and ages of dependents: ________________________________________________
(h) Income, expense, asset & liability information:
Gross income from all sources (check one):
$____________________ per _________ week/_________ month/________ year.
If now working, list your occupation:
and the name of your employer: _______________________________________________________
_________________________________________________________________________________
Source(s) of income, per _________ week/_________ month/________ year
if not from employment: _____________ (check one)
Workers’ Compensation Benefits $______________ Pension $______________
Social Security Disability $______________ Other $______________
Long Term Disability $______________ Other $______________
If spouse of applicant is employed, list occupation and name and address of his/her employer:
__________________________________________________________________________________
Reproduce as needed. (OVER) Form 112A - Revised 7/2019
