Washington > Workers Comp > Claims
Declaration Of Entitlement For Widow Or Widower Benefits F242-173-111 - Washington
| Declaration Of Entitlement For Widow Or Widower Benefits Form. This is a Washington form and can be used in Claims Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Department of Labor and Industries Pension Benefits PO Box 44281 Olympia WA 98504-4281 Date Claim No. Folio No. DECLARATION OF ENTITLEMENT For WIDOW OR WIDOWER 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 the widow/widower of the deceased named Mailing address City Residence is the same as MAILING address: If NO, list residence address State ZIP Name of deceased The children/dependents reside with me Yes No If NO, list names and addresses of dependents not residing with you. No Yes Any change in status of dependent children must be reported, such as death, marriage or change in custody that would alter the dependency circumstances. If there has been a change since you submitted the last Declaration of Entitlement, complete the following: State name of dependent, date of change and explanation. Your statement may change your monthly benefit. Failure to report dependent changes, remarriage or incarcerations in order to receive benefits for which you may not be entitled may result in civil or criminal charges. Has there been any type of change in marital status since you completed the last Declaration of Entitlement form (death of current spouse, divorce, marriage, etc)? Yes No If yes, give date and list status change. Since you last submitted the Declaration of Entitlement form have you been convicted of a crime and under sentence? Yes No If yes, when? Where? 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 F242-173-111 dec of ent widow or widower 10-04 American LegalNet, Inc. www.USCourtForms.com
|
|||||||
