Date Department of Labor and Industries Pension Benefits PO Box 44281 Olympia WA 98504-4281 Claim No. Folio No. DECLARATION OF ENTITLEMENT For GUARDIAN BENEFITS UNDER INDUSTRIAL INSURANCE Reminder: Your Signature is required If you are signing with power of attorney, submit a copy of that document if you have not done so already. For your protection, your signature is used for comparison with endorsement on checks payable to you. If you are signing yourself, please be sure to sign in the signature block or document will be considered incomplete and will be returned. For benefits to continue without interruption this Declaration of Entitlement must be completed in full, signed, notarized and returned within 30 days. 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 other who have minor or disabled children or dependents of the worker in their care and custody. This person now receives the pension benefits for the children/dependents. Print name of legal guardian or custodian Mailing address City State Residence is the same as MAILING address: ZIP Yes No If NO, list residence address. The children / dependents under 18 years old No Yes that reside with me. If NO, list names and addresses of dependents under 18 years old not residing with you. Any change in status of dependents or children for whom you are receiving pension benefits must be reported. Changes in dependency circumstances may require an adjustment in the monthly entitlement. Dependency changes include death, marriage, incarceration, emancipation or change in care and custody. Failure to report dependent changes or incarcerations in order to receive benefits for 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 Change If there has been a change of dependency please provide the following information: Name of dependent for which you are reporting the change Effective date of dependency change Social Security # (ID only) Explanation: Phone # Date Signature (required) Notary Signature and impression of seal or stamp are required. RCW 42.44.090(1) Notary Seal or Stamp Subscribed and sworn to before me this date Notary public signature For the state of Residing at Title My commission expires F242-173-222 dec of ent – guardian benefits 10-07 American LegalNet, Inc. www.FormsWorkflow.com