Department of Labor and Industries Pension Benefits PO Box 44281 Olympia WA 98504-4281 Date Declaration of Entitlement For Dependent of Deceased Worker Benefits Under Industrial Insurance Claim No. Folio No. For benefits to continue without interruption, this Declaration of Entitlement must be completed in full, signed, notarized and returned within 30 days. · · · Print name of dependent(s) Mailing Address City State Zip Code If you are signing yourself, please sign in the signature block or the document will be considered incomplete and will be returned. If you are signing with a power of attorney, submit a copy of the power of attorney. For your protection, your signature is used for comparison on checks made payable to you. Name of the deceased worker Relationship with the deceased worker Do you continue to be dependent upon the deceased worker's benefits? Yes No Your monthly income from all sources excluding the deceased worker: Is residence address the same as mailing address? Yes No If no, list residence address: $ Have you been convicted of a crime or incarcerated in the last year prior to completing this or any prior declaration form? No Yes If yes, When: Where: Are you now or have you ever received Social Security Administration (SSA) benefits? No Yes Any changes in status of dependents or children for whom you are receiving pension benefits must be reported. Changes in dependency circumstances may alter your monthly benefit. Dependency changes include: death; marriage; declaration of a registered domestic partnership; incarceration; emancipation; or change in care and custody. Failure to report work activities, status changes or incarcerations in order to receive benefits for which you may not be entitled may result in civil or criminal charges. Signature (required) Phone number Date Social Security Number (ID only) Notary Seal or Stamp Notary signature and impression of seal or stamp are required. RCW 42.44.090(1) Subscribed and sworn to before me this date Notary public signature For the state of Residing at Title My commission expires F242-422-000 Declaration of Entitlement ­ Dependent of Deceased Worker 02-2016 American LegalNet, Inc. www.FormsWorkFlow.com