Court Opinion

ID: 4560290
Source: CourtListenerOpinion
Date Created: 2020-08-26 21:01:58.679178+00
Date Added: 2024-06-11T11:15:26.590971
License: Public Domain

FILED
Apr 23, 2019

10:02 AM(ET)
TENNESSEE COURT OF
WORKERS' COMPENSATION

CLAIMS

 

TENNESSE BUREAU OF WORKERS’ COMPENSATION
IN THE COURT OF WORKERS’ COMPENSATION CLAIMS
AT CHATTANOOGA
Anthony Montgomery, Docket No.: 2017-01-0884
Employee,
v.
Mitchell Industrial Tire Co., Inc.,
Employer,

State File No.: 13027-2017

)

)

)

)

)

and )
Great American Alliance Ins. Co., ) Judge Thomas Wyatt

Carrier, )

and )

Abigail Hudgens, Administrator of the )

Bureau of Workers’ Compensation )

Subsequent Injury and Vocational )

Recovery Fund. )

 

EXPEDITED HEARING ORDER FOR MEDICAL BENEFITS

 

This matter came before the Court on April 17, 2019, for an Expedited Hearing
requested by Anthony Montgomery. The central issue was whether Mr. Montgomery
proved his entitlement to specific medical treatment and temporary disability benefits.
For the ‘reasons set forth below, the Court grants Mr. Montgomery’s request for
psychological treatment and a diagnostic stellate ganglion block but denies his request for
cervical care and temporary disability benefits.

History of Claim

On February 15, 2017, Mr. Montgomery injured his left shoulder when a large,
heavy airplane tire rolled off a cart toward him and he attempted to push it away. The
impact caused his shoulder to pop and become immediately painful. Mitchell accepted
Mr. Montgomery’s left-shoulder injury as compensable and provided a panel from which
he selected orthopedist Dr. Benjamin Miller. Dr. Miller diagnosed a full-thickness tear of
the left rotator cuff, assigned restrictions, and recommended surgery.
Mitchell accommodated Mr. Montgomery’s restriction against any use of his left
arm while he waited for surgery to be scheduled. However, Mitchell terminated him on
April 10 for allegedly falling asleep on the job and for dishonesty because he denied the
incident occurred. Mr. Montgomery testified that he closed his eyes while on break
because the medication Dr. Miller prescribed made him chronically drowsy.

Phil Meadows, Mitchell’s vice-president for human resources, testified that
Mitchell has company rules prohibiting sleeping on the job and dishonesty that result in
immediate termination if violated. He stated Mitchell properly fired Mr. Montgomery
because its security video showed that Mr. Montgomery remained in the breakroom with
his eyes closed for forty-eight minutes on a ten-minute break. He further stated Mitchell
had additional good cause to fire Mr. Montgomery because he lied about sleeping on the
job when Mr. Meadows confronted him about the incident. Mr. Meadows testified
Mitchell would have accommodated Mr. Montgomery’s restrictions to allow him to work
full-time at his regular wage had it not terminated him for cause.

Mr. Montgomery underwent surgery on April 19. Two months later, Dr. Miller
noted that he still had “a lot of pain” in his left shoulder despite taking pain medication.
Dr. Miller limited his work activities to “sedentary duty only, no use of left arm.”! A
month later, Dr. Miller noted Mr. Montgomery’s continuing complaints of pain. He
discussed the concern that Mr. Montgomery’s continuing pain meant he had developed
chronic regional pain syndrome (CRPS).

Dr. Miller ordered an MRI to investigate the causes of Mr. Montgomery’s ongoing
pain. The MRI revealed a slight tear in the rotator cuff, inflammation around one of the
anchors surgically placed in the left shoulder, and marrow inflammation in the shoulder
joint. However, Dr. Miller did not think that a re-tear had developed and did not ascribe
Mr. Montgomery’s severe ongoing pain to the conditions shown on the MRI. Mr.
Montgomery reported continuing pain on July 20, at which time Dr. Miller wrote, “I feel
like he has complex regional pain syndrome of his left shoulder.”

The last note from Dr. Miller introduced into evidence does not identify the date
of the visit; however, the electronic signature affixed to the note indicates that Dr. Miller
reviewed the note on September 2. Mr. Montgomery contends the note documents that
Dr. Miller ordered a cervical MRI and referred him for neck treatment. On this issue, the
note states:

We will see if we can get him into Pain Management.” We talked about
getting a second opinion and they wanted to see if Dr. Smalley would

 

*Dr. Miller kept Mr. Montgomery on the same restrictions throughout his treatment. The note documenting his last
visit with Mr. Montgomery did not alter or lift the restrictions.

? Dr. Miller prescribed opioid pain medication throughout his treatment of Mr. Montgomery.

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see him. So, we will refer him to Dr. Smalley for a second opinion. I
will see him back to follow up with a nerve conduction study.

Dr. Miller discussed two diagnoses in this note: a full-thickness left rotator-cuff
tear and neck pain. Under the rotator-cuff diagnosis, Dr. Miller wrote: “ORTHOPEDIC
REFERRAL-Schedule within: provider’s discretion. Reason for Referral: 2™ opinion.”
Dr. Miller wrote under the cervical diagnosis that he ordered an EMG. The Court found
no documentation in Dr. Miller’s records that he ordered a cervical MRI. Also, the
records revealed no evidence that Mr. Montgomery saw Dr. Smalley for the second
opinion. Mitchell authorized Dr. John Blake to provide the pain management
recommended by Dr. Miller.

Dr. Blake first saw Mr. Montgomery on September 18, 2017. He noted that Mr.
Montgomery underwent left rotator-cuff surgery but developed chronic post-surgical pain
requiring long-term treatment by opioid pain medication. Dr. Blake diagnosed chronic
post-traumatic pain following left rotator-cuff surgery and noted long-term opioid use.
He also reviewed an EMG that showed left carpal-tunnel syndrome and left-sided
cervical radiculopathy. Finally, during the initial visit, Dr. Blake assessed that Mr.
Montgomery was depressed and made a referral to a psychologist that Mitchell did not
honor.

Dr. Blake started Mr. Montgomery on a non-opioid pain medication, a muscle
relaxer, and a sleep aid. When that regimen proved ineffective to manage Mr.
Montgomery’s pain, Dr. Blake began prescribing hydrocodone, an opioid, in November
2017. Mr. Montgomery has remained on hydrocodone since. Dr. Blake ordered a stellate
ganglion block in August 2018 because Mr. Montgomery exhibited some of the
symptoms of CRPS. However, it was not performed because Mitchell denied the
procedure following Utilization Review. Dr. Blake testified by deposition that he
recommended the block to determine if Mr. Montgomery had actually developed CRPS
because non-opioid treatment options are available to treat CRPS. He stated he had
sufficient clinical indication that Mr. Montgomery had developed CRPS to justify the
reasonableness and necessity of the diagnostic block.

Orthopedist Dr. James Cain performed the Utilization Review of the stellate
ganglion block, considering it under the ODG treatment guidelines. He did not see Mr.
Montgomery personally and twice on the same day attempted unsuccessfully to speak to
Dr. Blake for a peer-to-peer review.

 

> At one point, Dr. Blake wrote that Mr. Montgomery had decided he did not want to undergo the recommended
block. However, Mr. Montgomery testified during the hearing that he did want to undergo the procedure.

3
Dr. Cain concluded that stellate ganglion blocks did not qualify as reasonable and
necessary treatment under the ODG guidelines. Specifically, he stated that the blocks
were inappropriate because Dr. Blake (1) had not ruled out all other diagnoses but CRPS
and (2) had not evaluated Mr. Montgomery for CRPS under a protocol specified in the
ODG. Neither Mr. Montgomery nor Dr. Blake appealed Dr. Cain’s denial.

Dr. Blake testified as follows on Mr. Montgomery’s need for psychiatric care:

Q. Doctor, did Mr. Montgomery report to you that he was
experiencing symptoms of depression?

A. Yes[.] So in the first visit... we do a depression
screen[.] His score was elevated[.] He stated that his depression was
related to his loss of function and inability to work. And I referred him
to a psychologist for further evaluation and treatment.

Q. [J So, in your opinion, he needs treatment for the
depression, you said, with a psychologist; is that right?

A. Yes, sir.

During the doctor’s deposition, Mr. Montgomery asked Dr. Blake to address the
sedative effect of the prescribed opioid Mr. Montgomery was taking at the time Mitchell
terminated him. Dr. Blake testified that the medication may or may not cause drowsiness
depending on the person taking it.

Mr. Montgomery filed a Petition for Benefit Determination seeking
authorization for the cervical MRI allegedly ordered by Dr. Miller; referrals for cervical
and psychiatric care; authorization for the stellate ganglion block ordered by Dr. Miller;
and temporary disability benefits beginning the date Mitchell terminated him. Mitchell
countered that Mr. Montgomery did not prove that his alleged depression and neck pain
arose primarily out of and in the course and scope of employment. Further, it urged the
Court to uphold the Utilization Review denial of the stellate ganglion block. Finally,
Mitchell argued that Mr. Montgomery is not entitled to temporary disability benefits
because it had good cause to terminate him for sleeping on the job and lying about it. It
added that had Mr. Montgomery not been fired for cause, he would have earned his full
weekly wages at Mitchell, which would have accommodated his restrictions as it did
before he was terminated.

Findings of Fact and Conclusions of Law

At an expedited hearing, Mr. Montgomery must provide sufficient evidence from
which the Court can determine he is likely to prevail at a hearing on the merits. McCord

4
v. Advantage Human Resourcing, 2015 TN Wrk. Comp. App. Bd. LEXIS 6, at *7-8, 9
(Mar. 27, 2015). Specifically, resolution of the present issues turns on whether Mr.
Montgomery proved entitlement to specific treatment plus temporary disability benefits
after Mitchell terminated him.

Medical Benefits
Cervical Care

The Court first considers whether Mr. Montgomery established that he would
likely prevail at trial in proving entitlement to a cervical MRI and/or a referral to a
physician for cervical care. Upon a thorough review of Dr. Miller’s records, the Court
finds no referral for a cervical MRI. He ordered an EMG, which Dr. Blake indicated Mr.
Montgomery received. Likewise, the Court does not find that Dr. Miller made a referral
for cervical care. The evidence indicates Dr. Miller discussed a referral for a second
opinion to Dr. Smalley on the left-shoulder injury but not a referral for cervical treatment.
On the basis of the above, the Court holds that Mr. Montgomery did not meet his burden
of proving entitlement to cervical care and denies the treatment at this time.

Psychological Care

The Court next addresses Mr. Montgomery’s request for a referral for
psychological care. Dr. Blake, whom Mitchell authorized to provide pain management,
testified that he referred Mr. Montgomery to a psychologist during the initial visit.
Mitchell did not explain why it failed to honor the referral other than to argue that Mr.
Montgomery did not prove by medical testimony that his depression is work-related.

Mitchell is correct that Mr. Montgomery has the burden to establish that he will
likely prevail at trial that his need for psychological care arises primarily out of and in the
course and scope of employment. See Tenn. Code Ann. § 50-6-102(14)(C) (2018), which
provides “[a]n injury causes . . . the need for medical treatment only if it has been shown
to a reasonable degree of medical certainty that [the work injury] contributed more than
fifty percent (50%) in causing the . . . medical treatment, considering all causes.” The
Court holds that Mr. Montgomery met his burden of proof with Dr. Blake’s testimony.
Dr. Blake testified that he diagnosed Mr. Montgomery with depression and made a
referral under workers’ compensation because Mr. Montgomery related his depression to
the loss of function and inability to work brought on by his work injury.

Tennessee Code Annotated section 50-6-204(h) addresses an injured employee’s
entitlement to psychological care. It states that “[a]ll psychological or psychiatric
services available [to an employee] shall be rendered only by psychologists or
psychiatrists and shall be limited to those ordered upon the referral of physicians
authorized under subdivision (a)(3).” Since Mitchell authorized Dr. Blake to provide

5
treatment following the authorized treating physician’s referral, Dr. Blake qualifies as a
physician authorized under subsection 204(h) to make a referral to a psychologist. For
these reasons, the Court holds that Mitchell shall promptly provide Mr. Montgomery a
panel of psychologists and/or psychiatrists from which he may select a provider for
treatment of his compensable depression.

Stellate Ganglion Block

Whether Mr. Montgomery is entitled to undergo the nerve block recommended by
Dr. Blake pits the differing opinions of the authorized treating physician and a Utilization
Review physician on what constitutes reasonable and necessary treatment of Mr.
Montgomery’s left-shoulder injury. Since the Utilization Review physician invoked his
interpretation of the ODG treatment guidelines in support of his opinion, the Court
analyzes the issue in view of the Workers’ Compensation Appeals Board’s decision in
Morgan v. Macy’s, 2016 TN Wrk. Comp. App. Bd. LEXIS 39, at *15-17 (Aug. 31,
2017).

In Morgan, the Appeals Board recognized the presumption under Tennessee Code
Annotated section 50-6-204(a)(3)(H) in favor of the medical necessity of "any treatment
recommended by a physician or chiropractor selected pursuant to this subdivision (a)(3)
or by referral, if applicable." Jd., at *15. The Board went on to hold that the presumption
in favor of the authorized physician’s treatment recommendation must be rebutted by
clear and convincing evidence if the employee shows the recommended treatment
follows the statutory treatment guidelines. Otherwise, the employer can rebut the
presumption by a preponderance of the evidence.

Here, Mr. Montgomery did not establish that Dr. Blake’s recommendation for a
diagnostic stellate ganglion block followed the ODG treatment guidelines. For this
reason, Mitchell can rebut the presumption in favor of the necessity of the recommended
treatment by a preponderance of the evidence. Upon reviewing the evidence, the Court
holds that Mr. Montgomery will likely prevail at trial in showing that the nerve block
recommended by Dr. Blake constitutes reasonable and necessary treatment of his
compensable injury.

In reviewing expert testimony, the Court may consider the qualifications of the
experts, the circumstances of their evaluation, the information available to them, and the
evaluation of the importance of that information by other experts. The Court has the
discretion to conclude that the opinion of one expert should be accepted over that of
another expert because it contains the more probable explanation. Owens v. Sitters, Etc.,
2018 TN Wrk. Comp. App. Bd. LEXIS 26, at *18-19 (May 29, 2019).

Here, the Court holds that Mitchell did not overcome the statutory presumption of
necessity afforded Dr. Blake’s recommendation of a diagnostic stellate ganglion block.

6
In support of this holding, the Court considered that Dr. Blake has treated Mr.
Montgomery on numerous occasions, as opposed to making treatment decisions based
solely on a review of records as did Dr. Cain. Further, the Court considered the fact that
both treating physicians, Drs. Miller and Blake, made differential diagnoses of CRPS
after surgery, physical therapy, prescription of non-opioid medication, injections, and
long-term prescription of opioid medication failed to alleviate Mr. Montgomery’s left-
shoulder pain. Finally, the Court considered Dr. Blake’s assessment that a diagnostic
block to determine if Mr. Montgomery does suffer from CRPS, which can be treated
without opioid therapy, is reasonable when cast against the current long-term use of
opioids Mr. Montgomery endures.

In view of the above, Mitchell shall promptly authorize and schedule the
diagnostic stellate ganglion block recommended by Dr. Blake.

Temporary Disability Benefits

Finally, the Court addresses Mr. Montgomery’s claim for temporary disability
benefits. In Barrett v. Lithko Contracting, Inc., 2016 TN Wrk. Comp. App. Bd. LEXIS
70, at *9 (June 17, 2016), the Workers’ Compensation Appeals Board adopted the
holding of the Supreme Court in Carter v. First Source Furniture Grp., 92 S.W.3d 367,
368 (Tenn. 2002), that “an employee's termination due to a violation of a workplace rule
may relieve an employer of its obligation to pay temporary disability benefits if the
termination was related to the workplace violation.” Under this authority, an injured
employee is not entitled to temporary disability benefits if he is terminated for cause and
the employer would have accommodated the restrictions assigned.

Here, the Court holds that Mr. Montgomery failed to establish that he will likely
prevail at trial in proving his entitlement to temporary disability benefits. The Court
holds that Mitchell had the right to terminate Mr. Mitchell for overstaying his ten-minute
break by thirty-eight minutes because he was asleep. The Court holds that a company
rule against sleeping on the job is reasonably related to the efficient operation of an
employer’s business, and here, Mitchell had good cause to terminate Mr. Montgomery
for violation of the rule.

The Court finds unpersuasive Mr. Montgomery’s argument that the medication he
took for his work injury caused him to be uncontrollably drowsy and should excuse his
violation of the company rule. Mr. Montgomery presented no medical evidence that the
prescription medication for his injury caused him to sleep uncontrollably. Further, the
Court holds that Mitchell would have accommodated Mr. Montgomery’s restrictions as it
was doing at the time he was terminated. In that situation, had he not been terminated for
cause, he would have earned his full salary and, of course, not been entitled to temporary
disability benefits.
IT IS, THEREFORE, ORDERED as follows:

. Mitchell shall promptly provide Mr. Montgomery a panel of psychologists and/or
psychiatrists from which he can select a provider for authorized psychological
care.

. Mitchell shall promptly authorize Dr. Blake to schedule the diagnostic stellate
ganglion block he prescribed.

. Mr. Montgomery’s claims for cervical care and temporary disability benefits are
denied at this time.

. This matter is set for a Status Hearing on July 15, 2019, at 1:30 p.m. Eastern
Time. You must call (615) 741-3061or toll-free at (855) 747-1721 to participate
in the Status Hearing. You must call on the scheduled date and time to participate.
Failure to call in may result in a determination of the issues without your further
participation.

. Unless interlocutory appeal of the Expedited Hearing Order is filed,
compliance with this Order must occur no later than seven business days
from the date of entry of this Order as required by Tennessee Code
Annotated section 50-6-239(d)(3) (2018). The Insurer or Self-Insured
Employer must submit confirmation of compliance with this Order to the
Bureau by email to WCCompliance.Program@tn.goy no later than the
seventh business day after entry of this Order. Failure to submit the
necessary confirmation within the period of compliance may result in a
penalty assessment for non-compliance.

. For questions regarding compliance, please contact the Workers’ Compensation
Compliance Unit via email WCCompliance.Program@tn.gov or by calling (615)

253-1471 or (615) 532-1309.
Snemk Wh i

Judge Thomas Wyatt
Court of Workers’ Compensation Claims

ENTERED April 23, 2019.

 
APPENDIX
Exhibits: The Court introduced the following documentary exhibits into evidence:

Amended Affidavit of Anthony Montgomery

Transcript of the deposition of Dr. John Blake, with attached medical records
Medical records of Dr. Benjamin Miller

Utilization Review records of Dr. James Cain

Report of Dr. James Little

Separation Notice

Photograph of Mr. Montgomery in Mitchell’s breakroom

Transcript of the deposition of Anthony Montgomery

PADWPYWNS

Technical record: The Court considered the following filings of the parties:

1. Petition for Benefit Determination

2. Dispute Certification Notice

3. Order Granting Leave to Add Subsequent Injury and Vocational Recovery
Fund

4. Request for Expedited Hearing

Notice of Expedited Hearing

6. Subsequent Injury and Vocational Recovery Fund’s Expedited Hearing
Statement

7. Notice of Mitchell to Rely on Expedited Hearing Statement of the
Subsequent Injury and Vocational Recovery Fund

8. Supplemental Expedited Hearing Statement of the Subsequent Injury and
Vocational Recovery Fund

Nn
CERTIFICATE OF SERVICE

I hereby certify that a true and correct copy of the Expedited Hearing Order was
sent to the following recipients by the following methods of service on April 23, 2019.

 

 

 

 

 

 

 

 

 

Name Certified Via Email Email Address

Mail
Christopher Markel X cmarkel(@markelfirm.com
Employee Attorney jdickey@markelfirm.com
C. Douglas Dooley x Doug.dooley@leitnerfirm.com
Employer Attorney
Ronald McNutt Xx Ronald.mcnutt@tn.gov
Subsequent Injury
Fund

 

 

 

 

 

p Raise Wei Widen
PENNY SHRUM, COURT CLERK |"

we.courtclerk@tn.gov

10
 

Expedited Hearing Order Right to Appeal:

If you disagree with this Expedited Hearing Order, you may appeal to the Workers’
Compensation Appeals Board. To appeal an expedited hearing order, you must:

1. Complete the enclosed form entitled: “Expedited Hearing Notice of Appeal,” and file the
form with the Clerk of the Court of Workers’ Compensation Claims within seven
business days of the date the expedited hearing order was filed. When filing the Notice
of Appeal, you must serve a copy upon all parties.

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 of the 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 Indigency will
result in dismissal of the 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. If a transcript of
the proceedings is to be filed, a licensed court reporter must prepare the transcript and file
it with the court clerk within ten business days of the filing the Notice of
Appeal. Alternatively, you may file a statement of the evidence prepared jointly by both
parties within ten business 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 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. If you wish to file a position statement, you must file it with the court clerk within ten
business days after the deadline to file a transcript or statement of the evidence. The
party opposing the appeal may file a response with the court clerk within ten business
days after you file your position statement. All position statements should include: (1) a
statement summarizing the facts of the case from the evidence admitted during the
expedited hearing; (2) a statement summarizing the disposition of the case as a result of
the expedited hearing; (3) a statement of the issue(s) presented for review; and (4) an
argument, citing appropriate statutes, case law, or other authority.

For self-represented litigants: Help from an Ombudsman is available at 800-332-2667.
 

EXPEDITED HEARING NOTICE OF APPEAL
Tennessee Division of Workers’ Compensation

wwiw.tn.pov/labor-wid/weomp.shtml

wc.courtclerk@tn.gov
1-800-332-2667

Docket #:
State File #/YR:

 

Employee

Vv.

 

Employer
Notice
Notice is given that

 

[List name(s) of all appealing party(ies) on separate sheet if necessary]

appeals the order(s) of the Court of Workers’ Compensation Claims at

to the Workers’ Compensation Appeals

 

Board. [List the date(s) the order(s) was filed in the court clerk’s office]

Judge

 

Statement of the Issues
Provide a short and plain statement of the issues on appeal or basis for relief on appeal:

 

 

 

Additional Information
Type of Case [Check the most appropriate item]

[C1] Temporary disability benefits
L] Medical benefits for current injury
L] Medical benefits under prior order issued by the Court

List of Parties
Appellant (Requesting Party): At Hearing: LJEmployer LJEmployee

Address:

 

Party’s Phone: Email:

Attorney’s Name: BPR#:
Attorney’s Address: Phone:
Attorney’s City, State & Zip code:

 

Attorney’s Email:

 

* Attach an additional sheet for each additional Appellant *

LB-1099 rev. 10/18 Page 1 of 2 RDA 11082
Employee Name: SF#: DOI:

Appellee(s)
Appellee (Opposing Party): At Hearing: L1Employer LlEmployee

 

Appellee’s Address:

 

 

 

Appellee’s Phone: Email:
Attorney’s Name: BPR#:
Attorney’s Address: Phone:

 

 

Attorney’s City, State & Zip code:
Attorney’s Email:

* Attach an additional sheet for each additional Appellee *

CERTIFICATE OF SERVICE

I, , certify that | have forwarded a true and exact copy of this
Expedited Hearing Notice of Appeal by First Class, United States Mail, postage prepaid, to all parties
and/or their attorneys in this case in accordance with Rule 0800-02-22.01(2) of the Tennessee Rules
of Board of Workers’ Compensation Appeals on this the day of , 20

 

[Signature of appellant or attorney for appellant]

 

LB-1099 rev. 10/18 Page 2 of 2 RDA 11082
Tennessee Bureau of Workers’ Compensation
220 French Landing Drive, |I-B

I.

 

Nashville, TN 37243-1002

AFFIDAVIT OF INDIGENCY

 

800-332-2667

, having been duly sworn according to law, make oath that

because of my poverty, | 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:

 

3. Telephone Number:

5. Names and Ages of All Dependents:

 

 

 

 

6. lam employed by:

2. Address:

 

4. Date of Birth:

Relationship:
Relationship:
Relationship:

Relationship:

 

 

 

 

 

 

My employer's address is:

My employer’s phone number is:

 

 

7. My present monthly household income, after federai income and social security taxes are deducted, is:

$

8. | receive or expect to receive money from the following sources:

AFDC $
SSI $
Retirement $
Disability $

Unemployment $
Worker's Comp.$
Other $.

LB-1108 (REV 11/15)

per month
per month
per month
per month
per month
per month
per month

beginning

 

beginning

 

beginning

 

beginning

 

beginning,
beginning

 

beginning.

 

RDA 11082
9. My expenses are:.

 

 

 

Rent/House Payment $ permonth Medical/Dental $ per month

Groceries 3 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

 

 

 

 

| hereby declare under the penalty of perjury that the foregoing answers are true, correct, and complete
and that | am financially unable to pay the costs of this appeal.

 

APPELLANT

Sworn and subscribed before me, a notary public, this

day of , 20

 

NOTARY PUBLIC

My Commission Expires:

LB-1108 (REV 11/15) RDA 11082