KANSAS DEPARTMENT OF LABOR www.dol.ks.gov K-WC 112 (3-14) ANNUAL STATEMENT DO NOT SEND TO THE DIVISION OF WORKERS COMPENSATION. Send to the payer of benefits (insurance company, third party administrator, group-funded pool or employer of self-insured. Case: ________________________________________________________________ Docket number: _______________________ v.: ___________________________________________________________________ Social Security number: _________________________________ Pursuant to K.S.A. 44-510b(i), persons receiving benefits under this section shall submit this form annually to the payer of benefits. If the person receiving benefits under this section is a dependent child subject to a conservator, the conservator of such child shall submit this form. If such person fails to submit this form annually, the payer of benefits may notify the director of such failure and the director shall notify the person of the failure by certified mail with return receipt. If such person fails to submit the annual statement or fails to reasonably provide the required information within 30 days after receipt of the notice from the director, all compensation benefits paid under this section to such person shall be suspended until the annual statement is submitted in proper form to the payer of benefits. Name of Children of the Decedent _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ (Attach additional sheet if needed.) Age ________ ________ ________ ________ ________ Date of Birth _____________________ _____________________ _____________________ _____________________ _____________________ Are there any dependents 18 or older enrolled as a full-time student in an accredited institution of higher education or vocational education? YES NO If YES, indicate which child(ren): ____________________________________________________________________________________________________________ Has surviving spouse remarried? YES NO If YES, date of marriage: _______________________________ I hereby certify that the above information is true and correct to the best of my knowledge and belief. __________________________________________________________ Signature of surviving spouse __________________________________________________________ Printed name of surviving spouse ______________________ Date signed Federal Privacy Act Disclosure Section 7(a)(2)(B) The mandatory requirement that Social Security numbers be included on forms filed with the Division of Workers Compensation is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of 1974, since our regulations which require its disclosure were in existence before January 1, 1975. The number is used as a means of identifying all the various records in the Division of Workers Compensation pertaining to an individual. The use of Social Security numbers is made necessary because of the large number of applicants who have similar names and birth dates, and whose identities can only be distinguished by the Social Security number. DIVISION OF WORKERS COMPENSATION 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 American LegalNet, Inc. www.FormsWorkFlow.com