Date Department of Labor and Industries Pension Benefits PO Box 44281 Olympia WA 98504-4281 Claim No. Folio No. DECLARATION OF ENTITLEMENT For WIDOW OR WIDOWER 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. The children/dependents under 18 years old Yes No that reside with me. If NO, list names and addresses of dependents under 18 years old not residing with you. Print name of the widow/widower of the deceased named Mailing address City State Residence is the same as MAILING address: If NO, list residence address ZIP Yes No 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, Yes marriage, etc)? 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? Social Security # (ID only) Where? Phone # 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 F242-173-111 dec of ent – widow or widower 10-07 American LegalNet, Inc. www.FormsWorkflow.com