This form is filed at the lump sum conference. It is used by the employee to certify that there are no outstanding liens on the case, with any of the following parties:
  • the Department of Public Welfare
  • the Department of Revenue Child Support Unit - DOR Lien Release Request Guidance pdf format of DOR Lien Release Request
  • Veteran's Services
  • prior counsel
  • any medical, dental, hospital or disability income provider.

    Print Form 116C  pdf format of form-116C.pdf