VERIFICATION STATE OF CALIFORNIA County of ____________________________________ I, the undersigned, say that I am ____________________________________, a party to this action. I have read the foregoing Application for Discrimination Benefits Pursuant to Labor Code Section 132a and know the contents thereof, and that the same is true of my own knowledge, except as to the matters which are therein stated upon my information or belief, and as to those matters that I believe to be true. I declare under penalty of perjury that the foregoing is true and correct. Executed on ______________________, at ______________________________, California. __________________________________ Petitioner April 2014 American LegalNet, Inc. www.FormsWorkFlow.com