VERIFICATION STATE OF CALIFORNIA County of ___________________________________________ I, the undersigned, say that I am ________________________________________, a party to this action. I have read the foregoing Petition for Benefits for Serious and Willful Misconduct of Employer Pursuant to Labor Code Section 4553 and know the contents thereof, and that the same is true of my own knowledge, except as to the maters 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