Fillable Determination Application for Indigent (Colorado DORA)

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Determination Application for Indigent (Colorado DORA)

On average this form takes 14 minutes to complete

The Determination Application for Indigent (Colorado DORA) form is 4 pages long and contains:

  • 0 signatures
  • 3 check-boxes
  • 53 other fields

Country of origin: US
File type: PDF

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Colorado Department of Regulatory Agencies (DORA) is responsible for professional licensing and consumer protection in Colorado USA.

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1
Instructions for Completing the
Application for Indigent
Determination
Please read all pages
This form is “fillable.” That means you can type the information onto
the form from your computer and print the form. You will not be able
to save the form onto your computer’s hard drive.
When you open the form, click in the “Claimant”box (field), complete
the information, and use the tab key to navigate to the next field. Do
not use the Enter
key; pressing the Enter key will only page down.
Each field has been limited. This means that you cannot
continue to
type information into a field if it doesn’t fit into the space provided.
Use numbers only
to fill in the fields for Social Security Number and
dollar amounts. Do not use dashes or dollar signs; when you tab out
of the field, it will fill in automatically. If a dollar amount contains
cents, do
type the period. To fill in a check box, click inside the box
with your mouse.
To clear or delete all the information you have typed onto the form,
click on the red “Clear Entire Form” button. To clear all information on
a single page, click on the red “Clear This Page” button. To change
the information in one field, use the backspace or delete key.
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2
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“Check Box”
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WC35 Rev 01/06 Page 1 of 2
(See other side)
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
633 17
th
ST., SUITE 400
DENVER, CO 80202-3626
APPLICATION FOR INDIGENT DETERMINATION
Request For Hearing Transcript
Pursuant to C.R.S. Section 8-43-213
Claimant ______________________________________
W.C. number ___________________________________
Employer _____________________________________
Social security number ___________________________
Insurance carrier _______________________________
Carrier number _________________________________
Household status of claimant:
Number of dependents:
Single _______
Married _________
Spouse ________
Other ________
Separated _______
Divorced ________
Children _______
Ages of children:
Bank accounts or other financial accounts:
Account balance:
Checking
At ____________________________________________________
$ ___________________________
Savings
At ____________________________________________________
$ ___________________________
Other
At ____________________________________________________
$ ___________________________
Amount of cash on hand...............................................................................................
$ ___________________________
Value of property and real estate owned: $ ______________
Vehicles owned:
Year ______
Make ________________
Value $ __________
Year ______
Make ________________
Value $ __________
Gross monthly income of all
household members:
Monthly expenses of household:
Earnings - claimant
$ ______________________
Rent/House payment
$_______________________
Earnings - spouse
$_______________________
Utilities
$_______________________
Earnings - other members
$ ______________________
Food
$_______________________
List other sources of income for household members. Include
income such as AFDC, unemployment, welfare, social security,
retirement pension, etc.:
Clothing
$_______________________
$ ______________________
Alimony/Child support
$
$_______________________
Medical bills
$_______________________
$_______________________
Installment payments
$_______________________
$_______________________
Other
$_______________________
Total household income:
$_______________________
Total monthly
expenses:
$ ______________________
Back to Instructions
Clear Entire Form
WC35 Rev 01/06 Page 2 of 2
If further information or clarification is needed, it may be necessary for the Division of Workers =
Compensation to contact the claimant, in writing. Please provide the claimant’s current address below:
Street/PO Box
City, State, Zip
If claimant is represented by an attorney, please provide name and address of attorney below:
Attorney name
Street/PO Box
City, State, Zip
Please note: A copy of this application will be sent to the insurance company, self-insured employer or
uninsured employer and all attorneys. The Director, in considering this request, may use a standard of
indigency accepted by the courts of the State of Colorado as an initial guideline. Please see the Supreme
Court Directive on the subject of indigency and court-appointed attorneys. A dispute between the parties
regarding this application may be referred for hearing before an Administrative Law Judge.
I certify the information contained in this application is true and correct.
Claimant signature
State of Colorado
County of
Sworn to before me and subscribed in my presence this
day of _____________ , _____.
Notary public
SEAL
Address
My commission expires
If, for the purpose of obtaining any order, benefit, award, compensation, or payment under the provisions of
articles 40 to 47 of [title 8], either for self-gain or for the benefit of any other person, anyone willfully makes a
false statement or representation material to the claim, such person commits a class 5 felony and shall be
punished as provided in Section 18-1 .3-401, C.R.S., and shall forfeit all right to compensation under said
articles upon conviction of such offense. (Section 8-43-402, C.R.S.)
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Determination Application for Indigent (Colorado DORA)

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Completed 27 January 2021

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