The SF-6 form serves as a crucial document within the framework of the Arkansas Workers’ Compensation system, specifically under the authority of Ark. Code Ann. §11-9-527. This particular affidavit is indispensable for dependents of a deceased worker, who are not the spouse or child—such as a parent, brother, sister, grandparent, or grandchild—establishing their eligibility to receive benefits. Crafted by the Special Funds Division of the Arkansas Workers’ Compensation Commission located at 324 Spring Street, Little Rock, AR, the form mandates that the beneficiary acknowledge their dependency on the deceased worker and agree to notify the Death & Permanent Total Disability Trust Fund promptly upon their own death. This ensures the continuation of benefits up until the dependent's death. The form also carries a stern warning against any fraudulent activities, stating that knowingly making false statements or concealing information is a Class D felony, with penalties that benefit the Trust Fund. The submission of this affidavit, which needs to be notarized, is time-sensitive, requiring action within thirty days to avoid suspension of benefits. Through this process, the Arkansas Workers’ Compensation Commission reinforces its commitment to safeguarding the rights and benefits of workers and their dependents, while also upholding the integrity of the system against fraud.
| Question | Answer |
|---|---|
| Form Name | Form Sf 6 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | AWCC, ARKANSAS, Claimant, fwisd affidavit of residency |
Form
Rev.
Autho rity:
Ark. Code Ann.
A R K A NS A S W O R K E RS ’ C O M P E NS A TIO N C O M M I SS IO N
SPECIAL FUNDS DIVISION
324 Spring Street, P. O. Box 950, Little Rock, AR
AFFIDAVIT FOR DEPENDENTS OTHER THAN SPOUSE OR CHILD
(Parent, brother, sister, grandparent, grandchild)
Date:_____________________ |
Re: ____________________________ |
(Date Mailed) |
Claimant - AWCC File No. |
_________________________ |
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Dependent's Name |
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_________________________ |
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Address |
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_________________________ |
CERTIFIED MAIL |
Under the provisions of Ark. Code Ann.
We ask you to complete, sign, have notarized, and return this Affidavit to our office at the address above within thirty (30) calendar days. Failure to do so will result in suspension of your benefit checks. If you have questions, please call us at
/s/ Death & Permanent Total Disability Trust Fund
AFFIDAVIT
I, ________________________, do certify that I was a dependent of ____________________, deceased,
Dependent's Name |
Claimant |
and have instructed family members or the
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Beneficiary’s signature |
State of |
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County of |
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Subscribed and sworn to before me this _______ day of _______________________, 2________.
My commission expires:
Notary Public
Ark. Code Ann.
or conceals any material information, or who willfully and knowingly employs any device, sch eme, or artifice for the purpose of: obtaining an y benefit or payment; defeating or wron gfully increasing or wrongfully decreasing any claim for benefit or payment; or obtaining or avoiding workers’ compensation coverage or avoiding payment of the proper insurance premium, or who aids and abets for any of said purposes, under this chapter shall be guilty of a Class D felony. Fifty percent (50% ) of any criminal fine imposed and collected under ... this section shall be paid and allocated in accordance with applicable law to the Death and Permanent Total Disability Trust Fund administered by the Workers’ Com pens ation C omm ission .”