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California Workers' Comp Lien Affidavit

This document is an affidavit from a defendant's attorney regarding the resolution of liens in a workers' compensation case. It requires the attorney to list all lien claims, detail the nature and date of resolution efforts, and state the results. The affidavit must be signed under penalty of perjury and indicates the location and date of execution.

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94 views3 pages

California Workers' Comp Lien Affidavit

This document is an affidavit from a defendant's attorney regarding the resolution of liens in a workers' compensation case. It requires the attorney to list all lien claims, detail the nature and date of resolution efforts, and state the results. The affidavit must be signed under penalty of perjury and indicates the location and date of execution.

Uploaded by

ka
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

STATE OF CALIFORNIA

WORKERS' COMPENSATION APPEALS BOARD

Case No.

Applicant,

vs. AFFIDAVIT OF DEFENDANT


RE: RESOLUTION OF LIENS

Defendants.

I, , am the attorney or representative for defendant

in the above-entitled matter.

I have made the following good faith efforts to resolve each of the Iiens in this case.

List ALL lien claims below. Use supplemental pages as necessary.

Lien Claimant Nature and Date of Lien Resolution Efforts Result

I declare under penalty of perjury that the foregoing is true and correct and that this affidavit was executed at ,

California on , .

American LegalNet, Inc.


www.FormsWorkflow.com
Supplemental Page Re: Resolution of Liens

Case No.

Lien Claimant Nature and Date of Lien Resolution Efforts Result

I declare under penalty of perjury that the foregoing is true and correct and that this affidavit was executed at

California, on , .

American LegalNet, Inc.


www.FormsWorkflow.com
American LegalNet, Inc.
www.FormsWorkflow.com

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