Date Department of Labor and Industries Pension Benefits PO Box 44281 Olympia WA 98504-4281 Claim No. Folio No. DECLARATION OF ENTITLEMENT For DEPENDENT OF DECEASED WORKER BENEFITS UNDER INDUSTRIAL INSURANCE Reminder: Your Signature is required 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. If you are signing yourself, please be sure to sign in the signature block or document will be considered incomplete and will be returned. For benefits to continue without interruption this Declaration of Entitlement must be completed in full, signed, notarized and returned within 30 days. Print name(s) of dependent(s) I/we was/were financially dependent upon the deceased named: Mailing address Relationship was: City State Residence is the same as MAILING address: If NO, list residence address. ZIP Yes No The children / dependents under 18 years old Yes No that reside with me. If NO, list the names and addresses of dependents under 18 years old not residing with you. The circumstances of my/our dependency have not changed since the fatal industrial accident and proof of my/our claim was submitted to the Department of Labor and Industries. Any change in status of this claim must be reported, such as death of a dependent, financial aid and acquisition of property which would alter the dependency circumstances. If there has been any change since you submitted the last declaration, please complete the following: Your statement may change your monthly benefit. Failure to report employment, marriage, dependent changes or incarcerations to continue receiving benefits may result in civil or criminal charges. Relationship of any dependent who has died Do you continue to be dependent? Yes Date of death My/our income per month from all sources, exclusive of this person is: $ No Since you last submitted the Declaration of Entitlement form have you been convicted of a crime and under sentence? Yes No If yes, when? Social Security # (ID only) Phone # Where? Date Signature (required) Notary Signature and impression of seal or stamp are required. RCW 42.44.090(1) Notary Seal or Stamp Subscribed and sworn to before me this date Notary public signature For the state of Residing at Title My commission expires F242-173-333 dec of ent – dependent of deceased worker 10-07 American LegalNet, Inc. www.FormsWorkflow.com