Free Form 87A - North Carolina

North Carolina Industrial Commission

IC File #

AFFIDAVIT OF ACCRUED ARREARAGES G.S. 97-87(d)
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act

Emp. Code # Carrier Code # Employer FEIN
The I.C. File # is the unique identifier for this injury. It will be provided by return letter and is to be referenced in all future correspondence..

I.C. No. ____________; _________________, Employee, Plaintiff; v. _________________________, Employer; and __________________________ Carrier; Defendants. The undersigned, being first duly sworn, deposes and says: 1. The Certificate of Accrued Arrearages or a certified copy of the award which is attached to this affidavit has become final and the time for making payment under the award has expired. (Affiant may add any further necessary information):

2. All appeal rights of the liable parties have expired. This the day of , 20 . ____________________________________________
Signature: Claimant Attorney

____________________________________________
Address

____________________________________________
City, State, Zip Code

____________________________________________
Telephone

Sworn to and subscribed before me this _______ day of _________, 20___. _______________________________ Notary Public My Commission Expires: __________
MAIL TO: CLERK OF SUPERIOR COURT WHERE JUDGMENT IS SOUGHT, ALONG WITH CERTIFICATE OF ACCRUED ARREARAGES AS COMPLETED BY NCIC (FORM 87C)

FORM 87A 3/03 PAGE 1 OF 1

FORM 87A