DECLARATION PURSUANT TO LABOR CODE SECTION 4906(h) Pursuant to Labor Code Section 4906(h), I declare under penalty of perjury that I have not violated Section 139.3 and I have not offered, delivered, received, or accepted any rebate, refund, commission, preference, patronage dividend, discount, or other consideration, whether in the form of money or otherwise, as compensation or inducement for any referred examination or evaluation. Date: Signature Before signing this form, you should be aware that: 223Any person who makes or causes to be made any knowingly false or fraudulent material statement or representation for the purpose of obtaining or denying workers222 compensation benefits or payments is guilty of a felony.224 American LegalNet, Inc. www.FormsWorkFlow.com