Court Opinion

ID: 4560489
Source: CourtListenerOpinion
Date Created: 2020-08-26 21:02:14.557182+00
Date Added: 2024-06-11T11:16:02.874564
License: Public Domain

FILED
                                                                                 Nov 21, 2019
                                                                                 03:36 PM(CT)
                                                                              TENNESSEE COURT OF
                                                                             WORKERS' COMPENSATION
                                                                                    CLAIMS

            TENNESSEE BUREAU OF WORKERS' COMPENSATION
           IN THE COURT OF WORKERS' COMPENSATION CLAIMS
                          AT MURFREESBORO

LEON NEWMAN, JR.,                            )   Docket No.: 2019-05-0606
        Employee,                            )
v.                                           )
                                             )
EARTH SOLUTIONS, INC.                        )   State File No.: 35536-2017
         Employer,                           )
And                                          )
                                             )
BRIDGEFIELD CAS. INS. CO.,                   )   Judge Robert Durham
         Insurer.                            )

     EXPEDITED HEARING ORDER GRANTING MEDICAL BENEFITS AND
                 TEMPORARY DISABILITY BENEFITS

        The Court conducted an expedited hearing on November 13, 2019 to determine
whether Mr. Newman is entitled to additional and temporary disability benefits. The
primary medical issue is whether Mr. Newman's current left-sided complaints are due to
the stress placed on the spinal discs below the ones previously operated on, thus making
additional fusions reasonable and necessary. The Court holds Mr. Newman established
that he is likely to prove that the additional fusions are reasonable and necessary for
treatment of his work-related injury, and he is not yet at maximum medical improvement.

                                    History of Claim

        According to his affidavit and testimony, Mr. Newman was driving a truck hauling
an empty low-boy trailer in the course and scope of his employment with Earth Solutions
when another truck "t-boned" him on May 1, 2017. Mr. Newman asserted the accident
caused severe pain in his neck, which radiated into his right shoulder blade and across his
collarbone. He also testified that he had never experienced these symptoms or any
limitations on his ability to work before the accident. Earth Solutions accepted his claim
and eventually authorized care with orthopedist Juris Shibayama, M.D.

      Dr. Shibayama first saw Mr. Newman on November 30. The record documents

                                             1
complaints of right neck, clavicle, and shoulder pain, but does not mention any left-sided
issues. An MRI, as reviewed by the radiologist, revealed moderate left, mild right C5-
C6 foraminal stenosis and canal stenosis as well as bilateral foraminal stenosis and canal
stenosis at C6-7. 1 The radiologist also noted broad disc osteophyte complexes at C3-4
and C4-5 with minimal stenosis. After reviewing the MRI himself, Dr. Shibayama
diagnosed cervical radiculopathy, which he primarily related to the accident. He
performed cervical fusions at C5-6 and C6-7 in June 2018.

       Mr. Newman testified that the surgery substantially relieved his right-sided
symptoms, but three days afterward he began suffering severe pain in the left side of his
neck, down his left shoulder blade, and into his upper arm. An August 18 CT scan, as
interpreted by the radiologist, revealed worsening stenosis at C2-3 and C3-4 when
compared to the pre-surgery MRI. The radiologist also felt there was "moderately severe
left neuroforaminal encroachment with probable contact of the exiting C6 nerve root" at
the C5-6 level.

       Dr. Shibayama felt the CT scan revealed advancing stenosis at C3-5 which was
"much worse" than the pre-surgery MRI showed. He ordered another MRI, which the
radiologist interpreted as no significant abnormalities at C3-4, and an osteophyte at C4-5
which caused mild cord deformity.

        Based on the tests, Dr. Shibayama diagnosed "adjacent segment degeneration from
fusion," which was caused by enlarging the space between the discs being fused in order
to put in the plate, thus placing increased pressure on the adjacent discs. He felt the
increased pressure was 80% responsible for the rapid degeneration at C3-5 and additional
fusions were needed at those levels to alleviate Mr. Newman's pain. He also
recommended pain management and kept Mr. Newman off work. Earth Solutions did not
authorize the fusions or pain management, although it continued to pay temporary
disability benefits.

        Instead of authorizing surgery, Earth Solutions sent Mr. Newman for an
independent medical evaluation with orthopedist Gray Stahlman, M.D. Dr. Stahlman
testified that Mr. Newman complained of severe left neck, shoulder girdle, and arm pain
with weakness that began three days after the surgery. He could not lift his shoulder
more than forty-five degrees, and Dr. Stahlman suspected atrophy in his left arm.

      Dr. Stahlman also reviewed the CT and MRis. He felt the fusions at C5-7 were
appropriate and the cages were properly placed, although he noted that the disc spacing at
C5-6, was "particularly distracted," meaning that the disc space had been opened up by

     Spinal stenosis is defined as the "abnormal narrowing of the spaces in the spine."
h.ngs://www.mayoclinic.org/diseases-conditions/spinal- tenosis/symptom -causes/syc-20352961 (last
visited Nov. 21, 2019).

                                                2
the cage to approximately 100 percent from the initial spacing. Further, he did not
observe any appreciable difference in stenosis at the C3-5 levels between the pre- and
post-surgery MRis. In fact, he said they were "essentially identical."

        Based on the exam and record review, Dr. Stahlman believed that Mr. Newman
likely suffered from a stretch of his spinal cord and nerves from the C5-6 disc space
distraction. Alternatively, his pain could also be caused by a stretch of one or more
nerve groups in his left neck and shoulder while he was positioned for surgery. Thus,
though he believed Mr. Newman's post-surgical condition was most likely due to the
fusions, he thought it unlikely that the symptoms were due to degenerative changes at
C3-5 since the changes were the same as before the surgery and Mr. Newman's
symptoms manifested themselves in a "markedly different" way immediately after
surgery. He did not believe additional fusions would alleviate all of Mr. Newman's
symptoms, although he conceded surgery could possibly, but not likely, provide some
benefit.

       Instead of surgery, Dr. Stahlman recommended that Mr. Newman undergo
interventional pain management and physical therapy. He feared that Mr. Newman was
developing adhesive capsulitis in his left shoulder due to his pain, and possibly complex
regional pain syndrome from a nerve injury. He did not believe there were any other
options for treatment. In light of Dr. Stahlman's IME, Earth Solutions denied surgery.

       Mr. Newman then underwent an EMG, which did not reveal any cervical
radiculopathy. He also returned to Dr. Shibayama on January 31, 2019. Due to the
surgery denial, Dr. Shibayama placed Mr. Newman at maximum medical improvement
(MMI). However, he explained that he did this because of the denial, since he had
nothing more to offer Mr. Newman and his "hands [were] tied." Later, he withdrew this
MMI assignment in a letter to Mr. Newman's counsel as well as in his deposition, where
he made it clear that that he only placed Mr. Newman at MMI so that he could possibly
obtain surgery through his private insurance. Even though Dr. Shibayama placed Mr.
Newman at MMI on January 31, he ordered pain management and kept him off work.

       Instead of pain management, Earth Solutions sent Mr. Newman to Robert Todd,
M.D. upon Dr. Stahlman's recommendation. Dr. Todd did not give his opinion as to the
source of Mr. Newman's neuropathic pain, but he recommended a steroid injection at the
left C-6 level and additional medications. He also kept Mr. Newman off work. The
treatment did not alleviate Mr. Newman's symptoms.

       Mr. Newman next saw Dr. Jeffrey Hazlewood for pain management. In his initial
report, Dr. Hazlewood indicated that he did not find a non-organic component to Mr.
Newman's complaints nor any risk factors for addiction; therefore, opioids were an
acceptable mode of treatment. He also diagnosed a frozen left shoulder. As to causation,
Dr. Hazlewood felt that Mr. Newman might have sustained an injury to the brachia!

                                           3
plexus or a left-shoulder rotator cuff tear.

        After several months of pain management, a negative brachial plexus EMG study
and a negative left-shoulder MRI, Dr. Hazlewood stated he was at a loss as to the source
of Mr. Newman's complaints. Mr. Newman then returned to Dr. Shibayama in June
2019. On exam, he noted that Mr. Newman's complaints had worsened, and he
documented atrophy and weakness in Mr. Newman's left shoulder and arm. He renewed
his recommendation for additional fusions and indicated Mr. Newman could not work
until he had surgery.

       Earth Solutions sent the recommendation to utilization review with Dr. Robert
Holladay. In his July 4 report, Dr. Holladay stated the additional fusions were not
reasonable or necessary. As grounds, he cited the lack of significant MRI findings at the
C3-5 levels, the lack of response to the C6 steroid injection, and the ongoing left shoulder
evaluation. 2

       Following the denial, Dr. Shibayama appealed the decision to the Bureau's
medical director, Dr. Robert Snyder. Dr. Snyder reversed the UR decision, stating that
"the progressive symptoms and function are unlikely to stabilize without the surgery."
On July 23, 2019, he ordered the fusion be approved. As of the hearing, the surgery has
not been performed.

       In preparation for the hearing, the parties took the depositions of Drs. Shibayama
and Stahlman, which were made exhibits. Mr. Newman testified that before the accident
he was able to perform all of his job duties without limitation. Now, he remains in severe
pain on the left side from his neck to just above his left elbow. He demonstrated that he
cannot lift his left arm and it is very weak. He cannot perform simple functions such as
washing his hair or putting on a buttoned shirt, and it would be impossible for him to
drive a vehicle with a standard shift. He stated that he has not worked since his surgery.

                         Findings of Fact and Conclusions of Law

        Mr. Newman must present sufficient evidence establishing that he is likely to
prove at trial that he is entitled to additional surgery and temporary disability benefits.
See Tenn. Code Ann. § 50-6-239(d)(l). To establish entitlement, he must show he is
likely to prove: (1) a work-related injury; (2) the additional surgery is reasonable and
necessary for treating his injury; and, (3) he has yet to reach MMI and has been unable to
work since he last received temporary disability benefits. The Court will address each
issue in tum.

2
 Dr. Holladay did not have access to records documenting Mr. Newman's response to a left shoulder
bursa injection at the time of his evaluation. Mr. Newman testified that none of the post-surgical
procedures served to relieve his symptoms.

                                                4
       In order to establish compensability, Mr. Newman must prove that he sustained
an injury from a specific event that primarily arose out of and in the course of
employment identifiable by time and place. Tenn. Code Ann. § 50-6-102(14)(A). At the
hearing, Earth Solutions' counsel contended that Mr. Newman failed to provide sufficient
evidence establishing that the accident occurred while he was in the course and scope of
his employment. 3

       According to Mr. Newman's unrebutted evidence through affidavit and testimony,
he was driving a truck hauling an empty low-boy trailer in the course and scope of his
employment with Earth Solutions when he was "t-boned" by another truck. He then
managed to drive the truck back to Earth Solutions' yard. Dr. Shibayama, the authorized
physician, testified it is more likely than not that Mr. Newman's resulting symptoms and
need for fusions at C5-6 and C6-7 primarily arose out of the accident. This opinion is
presumed correct and Earth Solutions did not provide contrary medical evidence to rebut
it. Tenn. Code Ann. § 50-6-102(14)(E).             Indeed, Dr. Stahlman agreed with Dr.
Shibayama on these points. Thus, the Court holds that Mr. Newman is likely to prove that
he sustained an injury that primarily arose out of and in the course and scope of
employment on May 1, 2017, and that the fusions at C5-7 were reasonable and necessary
treatment for that injury.

       The more complex issue is whether Dr. Shibayama's recommendation for
additional fusions is reasonable and necessary for Mr. Newman's current left-sided
symptoms. It is not a question of causation-Drs. Shibayama and Stahlman agree to a
reasonable degree of medical certainty that the surgery is the primary cause of Mr.
Newman's current symptoms. This renders the condition causing the symptoms
compensable as well. Creasman v. Waves, Inc., 2018 Tn. Wrk. Comp. App. Bd. LEXIS
13, at *12 (April 16, 2018)(quoting Rogers v. Shaw, 813 S.W.2d 397, 400 (Tenn.
1991 )("[A]11 the medical consequences and sequelae that flow from the primary injury is
compensable.") The question the Court must address is whether the symptoms are due to
adjacent segment deterioration at the C3-5 levels, or are they due to a different problem
that will not be remedied by fusing the discs at those levels. On this issue, Dr.
Shibayama and Dr. Stahlman materially differ.

       When confronted with conflicting opinions, the Court has discretion to determine
which opinion to accept. Patterson v. Huff & Puff Trucking, 2018 Tn. Wrk. Comp. Bd.
LEXIS 33, at *9 (July 6, 2018). When doing so, the Court may consider, among other
things, "the qualifications of the experts, the circumstances of their examination, the
information available to them, and the evaluation of the importance of that information

3
 Until the hearing, Earth Solutions had not denied Mr. Newman's entitlement to benefits, only what the
scope of those benefits should be.

                                                  5
by other experts." Bass v. The Home Depot US.A, Inc., 2017 TN Wrk Comp. App. Bd.
LEXIS 36, at *9 (May 26, 2017).

       Here, both doctors are trained, orthopedic spine surgeons. Both have personally
examined Mr. Newman and have reviewed all relevant tests and records. In Dr.
Stahlman's favor is the fact that the post-surgery MRI seems to agree with his position
that there was little change at the C3-5 levels from before the surgery to justify Dr.
Shibayama's position of adjacent segment deterioration. Dr. Shibayama also admitted
that he widened the space on the right side of C6 considerably, and Dr. Stahlman
determined it was at least by 100%, which he believed could have stretched the spinal
cord. Further, the post-surgery EMG did not reveal any cervical radiculopathy at the C3-
5 levels. Finally, Dr. Holladay corroborated Dr. Stahlman's opinion regarding the pre-
vs. post-surgery degeneration at the C3-5 levels when he recommended denying surgery.

       Favoring Dr. Shibayama is the fact that he is Mr. Newman's authorized treating
physician, which entitles his opinion to a presumption of correctness. Tenn. Code Ann. §
50-6-204(H). Further, he performed the surgery and so had first-hand knowledge as to
the procedure as well as an opportunity to actually see Mr. Newman's spinal condition.
The post-surgery CT scan, as interpreted by the radiologist supported Dr. Shibayama's
opinion that the stenosis at C3-5 had worsened since the pre-surgery MRI.

        In addition, none of the tests and procedures proposed by Drs. Stahlman, Todd and
Hazlewood confirmed that Mr. Newman's symptoms came from a brachia! plexus nerve
stretch, a stretch of the spinal cord at C6, or his left rotator cuff. None of the procedures
improved Mr. Newman's symptoms either. In fact, Dr. Shibayama pointed to the fact
that the epidural steroid injection at C6 did not alleviate Mr. Newman's pain as evidence
that it did not originate at that level. According to Mr. Newman, his complaints have
worsened and Dr. Shibayama documented atrophy in his left arm at his last visit, which
was indicative of worsening nerve damage. Finally, Dr. Snyder agreed with Dr.
Shibayama's opinion when he reversed the UR denial and ordered Earth Solutions to
authorize surgery. 4

       After considering and weighing all the evidence, the Court finds that Earth
Solutions failed to overcome the presumption given to Dr. Shibayama's opinion. Thus,
the Court holds that Earth Solutions shall authorize the fusions at C3-5 as he
recommended.

      As to temporary total disability benefits, Mr. Newman must show the duration of
his work-related inability to work. See Shepherd v. Haren Const. Co., Inc., 2016 TN
4
 Earth Solutions also argued that Dr. Shibayama's reversal as to the date of MMI served to lessen his
credibility on other issues. However, his January 3 l medical record and his deposition made it clear that
he continued to believe surgery was necessary, and he only said Mr. Newman was at MMI because his
"hands were tied." The Court does not feel his decision injured his credibility.

                                                    6
Wrk. Comp. App. Bd. LEXIS 15, at *13 (Mar. 30, 2016). Here, even though Dr.
Shibayama stated Mr. Newman was at MMI on January 31, he did not allow him to
return to work. Dr. Stahlman believed that Mr. Newman was at MMI on January 31, but
he did not recommend that Mr. Newman return to work. Further, Dr. Todd expressly
took Mr. Newman off work while seeing him. No doctor has released Mr. Newman to
return to employment, and he testified that he continues to be unable to work. Of course,
Dr. Shibayama has now testified that he never truly felt Mr. Newman was at MMI, and
he has taken him off work until after surgery.

        Thus, the issue turns on whether Mr. Newman is, or ever was, at MMI for his
work-related injury. As stated above, the Court finds Dr. Shibayama's opinion more
persuasive as to Mr. Newman's condition, and that he adequately explained his reason for
stating Mr. Newman was at MMI on January 31. Thus, the Court holds that Mr. Newman
is entitled to temporary total disability benefits, at the stipulated compensation rate of
$683.50, from February 1, 2019 through present. The benefits shall continue until Dr.
Shibayama determines Mr. Newman is at MMI or is able to return to work.

      IT IS, THEREFORE, ORDERED that:

 1. Earth Solutions shall authorize and pay for Dr. Shibayama to perform the
    recommended fusions at C3-5.

 2. Earth Solutions shall pay Mr. Newman past temporary total disability benefits in the
    amount of $28,511. 71 and shall continue to pay these benefits until Mr. Newman
    reaches MMI or is able to return to work.

 3. This case is set for a Scheduling Hearing on January 13, 2020, at 2:00 p.m.
    Central Time. The parties must call 615-253-0010 or toll-free at 855-689-9049 to
    participate. Failure to call might result in a determination of the issues without your
    participation.

 4. 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). The
    Insurer or Self-Insured Employer must submit confirmation of compliance with this
    Order to the Bureau by email to WCCompliance.Program@tn.gov 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 at WCCompliance.Program@tn.gov.

                                            7
                                 ENTERED November -~} 2019.

                        ~~~      Court of Workers' Compensation Claims

                                     APPENDIX

Exhibits:

1.    Notice of First Payment of Compensation
2.    Final Medical Report
3.    Table of Contents for Medical Records
4.    UR Denial and Appeal
5.    Mr. Newman's affidavit
6.    Wage Statement
7.    First Report of Injury
8.    Collective Medical Records
9.    Deposition of Gray Stahlman, M.D.
10.   Deposition of Juris Shibayama, M.D.

Technical Record:

1.    Petition for Benefit Determination
2.    Dispute Certification Notice
3.    Request for Expedited Hearing
4.    Request for Expedited Hearing filed by Earth Solutions
5.    Dispute Certification Notice
6.    Mr. Newman's Witness and Exhibit List
7.    Earth Solutions' Witness List and Pre-Hearing Brief
8.    Mr. Newman's Pre-Hearing Brief

                                          8
                          CERTIFICATE OF SERVICE

    A copy of the Expedited Hearing Order Granting Benefits was sent as indicated on
        21 2019.
November_,

Name                    Certified   Email       Service sent to:
                         Mail
Jill Draughon                        x          jdraughon@hughesandcoleman.com
                                                dforbes(a),hughesandcoleman.com
 Seth Granda                         x          Seth.granda~petersonwhite.com

                                      Penny Shrum, Clerk of Court
                                      Court of Workers' Compensation Claims
                                      WC.CourtClerk@tn.gov

                                            9
                           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
                                                     www.tn.gov/labor-wfd/wcomp.shtml
                                                            wc.courtclerk@tn.gov
                                                               1-800-332-2667
                                                                                                      Docket #: _______________________
                                                                                                      State File #/YR: __________________

                    Employee
                    v.

                    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]

                           ☐ Temporary disability benefits
                           ☐ Medical benefits for current injury
                           ☐ Medical benefits under prior order issued by the Court
          List of Parties
          Appellant (Requesting Party):                               At Hearing: ☐Employer ☐Employee
          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: ☐Employer ☐Employee

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 I 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
                                        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 Comp.$ ________ per month               beginning
        Other           $ ________ per month             beginning

LB-1108 (REV 11/15)                                                                               RDA 11082
9. My expenses are:

        Rent/House Payment $ ________ per month          Medical/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

_______ day of                                    , 20_______.

NOTARY PUBLIC

My Commission Expires:

LB-1108 (REV 11/15)                                                                             RDA 11082