Department of Labor and Industries Pension Benefits PO Box 44281 Olympia WA 98504-4281 Date Declaration of Entitlement For Surviving Spouse or Registered Domestic Partners 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 surviving spouse or registered domestic partner Mailing Address City State Zip Code 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: If there has been a change in dependency circumstances for any child you receive benefits for, please provide the following information: Name of dependent; date of dependency change; and 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: What is your current martial/registered domestic partnership status? Is this a change since your last declaration form? No Yes If yes, give the date and list the change (i.e. marriage, divorce, registered domestic partnership, death, etc.) Date: Change: 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 F242-420-000 Declaration of Entitlement ­ Surviving Spouse or Registered Domestic Partnership 02-2016 American LegalNet, Inc. www.FormsWorkFlow.com