text:      FILED
     Nov 26, 2019
     03:20 PM(CT)
   TENNESSEE COURT OF
  WORKERS' COMPENSATION
         CLAIMS
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                                    I                                                       'I
  
  
  
                            Compensation Hearing Order Right to Appeal:
  
       If you disagree with this Compensation Hearing Order, you may appeal to the Workers'
  Compensation Appeals Board or the Tennessee Supreme Court. To appeal to the Workers'
  Compensation Appeals Board, you must:
  
      1. Complete the enclosed form entitled: "Compensation Hearing Notice of Appeal," and file
         the form with the Clerk of the Court of Workers' Compensation Claims within thirty
         calendar days of the date the compensation hearing order was filed. When filing the
         Notice of Appeal, you must serve a copy upon the opposing party (or attorney, if
         represented).
  
     2. You must pay, via check, money order, or credit card, a $75.00 filing fee within ten
        calendar days after filing of the Notice of Appeal. Payments can be made in-person at
        any Bureau office or by U.S. mail, hand-delivery, or other delivery service. In the
        alternative, you may file an Affidavit of Indigency (form available on the Bureau's
        website or any Bureau office) seeking a waiver ofthe filing fee. You must file the fully-
        completed Affidavit of Indigency within ten calendar days of filing the Notice of
        Appeal. Failure to timely pay the filing fee or file the Affidavit of lndigency will
        result in dismissal of your appeal.
  
     3~   You bear the responsibility of ensuring a complete record on appeal. You may request
          from the court clerk the audio recording of the hearing for a $25.00 fee. A licensed court
          reporter must prepare a transcript and file it with the court clerk within fifteen calendar
          days of the filing the Notice of Appeal. Alternatively, you may file a statement of the
          evidence prepared jointly by both parties within fifteen calendar days of the filing of the
          Notice of Appeal. The statement of the evidence must convey a complete and accurate
          account of the hearing. The Workers' Compensation Judge must approve the statement
          of the evidence before -the record is submitted to the Appeals Board. If the Appeals
          Board is called upon to review testimony or other proof concerning factual matters, the
          absence of a transcript or statement of the evidence can be a significant obstacle to
          meaningful appellate review.
  
     4. After the Workers' Compensation Judge approves the record and the court clerk transmits
        it to the Appeals Board, a docketing notice will be sent to the parties. The appealing
        party has fifteen calendar days after the date of that notice to submit a brief to the
        Appeals Board. See the Practices and Procedures of the Workers' Compensation
        Appeals Board.
  
  To appeal your case directly to the Tennessee Supreme Court, the Compensation Hearing
  Order must be final and you must comply with the Tennessee Rules of Appellate
  Procedure. If neither party timely files an appeal with the Appeals Board, the trial court's
  Order will become final by operation of law thirty calendar days after entry. See Tenn.
  Code Ann.§ 50-6-239(c)(7).
  For self-represented litigants: Help from an Ombudsman is available at 800-332-2667.
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                                      Tennessee Bureau of Workers' Compensation
                                             220 French Landing Drive, 1-B
                                               Nashville, TN 37243-1002
                                                        800-332-2667
  
                                                 AFFIDAVIT OF INDIGENCY
  
  
       I,                                                , having been duly sworn according to law, make oath that
       because of my poverty, I am unable to bear the costs of this appeal and request that the filing fee to appeal be
       waived. The following facts support my poverty.
  
       1. Full Name:_ _ _ _ __ _ _ _ _ __                       2. Address: - - - - - - - -- - - --
  
       3. Telephone Number: - - - - - - - - -                   4. Date of Birth: - - - - -- - - -- -
  
       5. Names and Ages of All Dependents:
  
               - - - - - - - - - - - - - - -- - Relationship: - - - - - - -- - - -- -
  
               - - - - - - - - - - - - - -- --                  Relationship: - - - - - -- - - -- - -
  
               - - - - - - - - - - -- - -- - - Relationship: - - - -- - -- - - - - -
  
               - - - - - - - - - - - - - - -- -                 Relationship: - - - - - - -- - - -- -
  
       6. I am employed by: - - - - - - - - - - -- - - -- - - - - - -- - - -- - -
  
               My employer's address is: - - - - -- - - - -- - - - - - -- - -- - - - -
  
               My employer's phone number is: - - - -- - - - -- - - - - - -- - - -- - -
  
       7. My present monthly household income, after federal income and social security taxes are deducted, is:
  
       $ _ _ _ _ _ __
  
       8. I receive or expect to receive money from the following sources:
  
               AFDC            $            per month           beginning
               SSI             $            per month           beginning
               Retirement      $            per month           beginning
               Disability      $            per month           beginning
               Unemployment $               per month           beginning
               Worker's Camp.$              per month           beginning
               Other           $            per month           beginning
  
  
  
       LB-1108 (REV 11/15)                                                                               RDA 11082
  9. My expenses are:     ! ~                                                      li
                                                                                    I
                            '
  
          Rent/House Payment $              per month     Med icai/Dental $ _ _ ___ per month
  
          Groceries       $           per month           Telephone       $ _ __ _ _ per month
          Electricity     $           per month           School Supplies $ _ _ _ _ _ per month
          Water           $           per month           Clothing        $ _ _ _ _ _ per month
          Gas             $           per month           Child Care      $ _ _ _ _ _ per month
          Transportation $            per month           Child Support   $ _ _ _ _ _ per month
          Car             $            per month
          Other           $           per month (describe:
  
  
  10. Assets:
  
          Automobile              $ _ _ _ __
                                                          (FMV) - - - - - - - - - -
          Checking/Savings Acct. $ _ _ _ __
          House                   $ _ _ __
                                                          (FMV) - - - - - - - - - -
          Other                   $ _ _ _ __              Describe:_ _ _ _ __ _ __ __
  
  
  11. My debts are:
  
          Amount Owed                     To Whom
  
  
  
  
  I hereby declare under the penalty of perjury that the foregoing answers are true, correct, and complete
  and that I am financially unable to pay the costs of this appeal.
  
  
  
  
  APPELLANT
  
  
  
  Sworn and subscribed before me, a notary public, this
  
  ____ dayof _____________________ , 20_ __
  
  
  
  
  NOTARY PUBLIC
  
  My Commission Expires:_ _ _ _ _ _ __
  
  
  
  
  LB-1108 (REV 11/15)                                                                          RDA 11082
  