Department of Labor and Industries Pension Benefits PO Box 44281 Olympia WA 98504-4281 Date Declaration of Entitlement For Disabled Child or Guardian 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. · 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. · · Print name of totally disabled worker Mailing Address City State Zip Code The definition of a Guardian includes a widow/widower who was receiving a pension and has since remarried but retains care and custody of the minor or disabled children or dependents. Or others who have minor or disabled children or dependents of the workers in their care and custody. This person now receives the pension benefits for the children/dependents. Do have children/dependents under 18 years old and/or who are disabled that don't live you with you? Yes No If yes, list names and addresses of the dependents not residing with you. Is residence address the same as mailing address? Yes No If no, list residence address: Any changes in status of dependents or children for whom you are receiving pension benefits must be reported. Changes in dependency may alter your monthly benefit. Dependency changes include: death; marriage; declaration of a registered domestic partner; incarceration; emancipation; or change in care and custody. Failure to report status change or incarcerations in order to receive benefits to which you may not be entitled may result in civil or criminal charges. Has there been a change in dependency circumstances for any child for which you are receiving benefits under Industrial Insurance? Yes No If yes, provide the following information: Name of dependent child for which you are reporting the change: Effective date of dependency change: Explanation: 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: 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 F242-421-000 Declaration of Entitlement ­ Disabled Child or Guardian American LegalNet, Inc. www.FormsWorkFlow.com