FORM 136
The Commonwealth of Massachusetts
Department of Industrial Accidents – Department 136
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 Board #
(If Known):
AFFIDAVIT OF INDIGENCE AND REQUEST
FOR WAIVER OF §11A(2) FEES
All questions must be answered in full or the word “none” inserted. If additional space is needed for any answer, an attached
sheet may be filed in addition to, but not in place of, the answer. Information contained herein will only be made available to
the parties and other persons as allowed under state or federal law. Give monthly figures. To convert weekly to monthly
figures, multiply the weekly amount by 4.3.
I. INFORMATION ON EMPLOYEE’S CLAIM
Employee’s Name:__________________________________ Social Security No.
1
: _____________________________
Employee’s Address: _______________________________ Date of Injury: __________________________________
__________________________________________________
Marital Status & No. of dependents: ___________________ Workers’ Comp. Insurer: _________________________
II. POVERTY AND ASSISTANCE QUALIFICATION [from SJC RULE 3:10 Section 1 (f)(i) and (ii)]:
_____ (a) I receive one of the following types of public assistance: Aid to Families with Dependent Children (AFDC),
Emergency Aid to Elderly, Disabled and Children (EAEDC), poverty related veterans’ benefits, food stamps,
refugee resettlement benefits, Medicaid, or Supplemental Security Income (SSI) or;
_____ (b) I receive an annual income, after taxes, of 125% or less of the current poverty threshold referred to in
M.G.L. c. 261 §27A (b).
2
III. MONTHLY INCOME FROM ALL SOURCES:
A. EMPLOYMENT OR SELF-EMPLOYMENT
1. GROSS: Self Spouse
3
a. Salary, Wages $_______________ $_______________
b. Tips, bonuses, self-employment income $_______________ $_______________
2. TOTAL (a plus b) $_______________ $_______________
3. DEDUCTIONS:
c. Federal Income Tax $_______________ $_______________
d. State Income Tax $_______________ $_______________
e. FICA/state or other retirement $_______________ $_______________
f. Union dues $_______________ $_______________
g. Business expense, if self-employed $_______________ $_______________
4. TOTAL DEDUCTIONS (c through g) $_______________ $_______________
5. ADJUSTED INCOME ( 2 minus 4) $_______________ $_______________
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1
Disclosing Social Security Number is voluntary. It will assist in the processing of your request.
2
The 125% figures shall be available from the Department. The citation to §625 of the Economic Opportunity Act in M.G.L. c. 261, §27A, as
recommended by St. 1980, c. 539, §5 has become §624. Pub. I. 88-425, title VI, §624 [42 U.S.C. §2971(d)]. As noted on “Affidavit of
Indigency and Request for Waiver, Substitution or State Payment of Fees and Costs” From CIV. P. 90, in note 1, the 125% figure is
substantially the same poverty standard used by legal services programs funded by the Federal Legal Services Corporation. 42 U.S.C.
§2996(a)(2)(A)&(B).
3
If there is a spouse, or person in substantially the same relationship, or parent (provided, in each instance, any such person lives in the same
residence as the applicant and contributes toward the household’s basic living costs), you must list income, amounts contributed by each to
basic living costs, and liquid assets for each person(s), in Parts III, IV and V in the column labeled “spouse”.
REPRODUCE AS NEEDED. Page 1 of 2 - Please complete reverse side. Form 136 - Revised 7/2019
