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Declaration Of Entitlement For Guardian Benefits F242-173-222 - Washington
| Declaration Of Entitlement For Guardian Benefits Form. This is a Washington form and can be used in Claims Workers Comp . |
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Department of Labor and Industries Pension Benefits PO Box 44281 Olympia WA 98504-4281 Date Claim No. Folio No. DECLARATION OF ENTITLEMENT For GUARDIAN BENEFITS UNDER INDUSTRIAL INSURANCE Reminder If you are signing with power of attorney, submit a copy of that document if you have not done so already. For your protection, your signature is used for comparison with endorsement on checks payable to you. For benefits to continue without interruption this Declaration of Entitlement must be completed in full, signed, notarized and returned within 30 days. Print name of legal guardian or custodian Mailing address City Residence is the same as MAILING address: If NO, list residence address State ZIP The definition of a Guardian includes a widow/widower who was receiving a pension and has since remarried but retains care and custody of the minor or disabled children or dependents. Or other who have minor or disabled children or dependents of the worker in their care and custody. This person now receives the pension benefits for the children/dependents. No The children / dependents reside with me No Yes If NO, list names and addresses of dependents not residing with you. Yes Any change in status of dependents or children for whom you are receiving pension benefits must be reported. Changes in dependency circumstances may require an adjustment in the monthly entitlement. Dependency changes include death, marriage, incarceration, emancipation or change in care and custody. Failure to report dependent changes or incarcerations in order to receive benefits for which you may not be entitled may result in civil or criminal charges. Has there been a change in dependency circumstances for any child for which you are receiving benefits under Industrial Insurance? No Change If there has been a change of dependency please provide the following information: Yes Name of dependent for which you are reporting the change Effective date of dependency change Explanation: Notary Signature Required Subscribed and sworn to before me this date Notary public signature For the state of Date Residing at Signature Under Penalty of perjury, I declare the above statements true. If you sign by mark, please have a witness print your name, then personally make your mark. Social Security # (ID only) Phone # If signed by mark, witness signature here. My commission expires F242-173-222 dec of ent guardian benefits 10-04 American LegalNet, Inc. www.USCourtForms.com
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