Date Department of Labor and Industries Pension Benefits PO Box 44281 Olympia WA 98504-4281 Claim No. Folio No. DECLARATION OF ENTITLEMENT For TOTALLY DISABLED WORKER 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. Print name of totally disabled worker Have you worked since you submitted the last declaration form? Mailing address Yes No If yes, when did you start? Number of days worked per week Average earnings per week $ City State ZIP Employer’s name and mailing address Residence is the same as MAILING address: If NO, list residence address Yes No 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. Have you ever been convicted of a crime and under sentence since you submitted the last Declaration of Entitlement form? Yes No If yes, when? Where? Has there been any type of change in your marital status (death of spouse, divorce, marriage, etc)? Yes No If yes, give date and list status change Social Security # (ID only) 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 F242-173-444 dec of ent – disabled worker 10-07 American LegalNet, Inc. www.FormsWorkflow.com