Fillable Pension Benefits PO Box 44281 Olympia WA 98504-4281 (Washington)

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Pension Benefits PO Box 44281 Olympia WA 98504-4281 (Washington)

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F242-423-000 Declaration of Entitlement – Totally Disabled Worker 11-2019
Department of Labor and Industries
Pension Benefits
PO Box 44281
Olympia WA 98504-4281
Date
Claim No.
Folio No.
Declaration of Entitlement
For Totally Disabled Worker Benefits Under
Industrial Insurance
For benefits to continue without interruption, this
Declaration of Entitlement must be completed in
full, signed, notarized and returned within 30 days.
Your signature is required.
• 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
Have you worked since you submitted the last declaration form?
Yes No If yes, when did you start?
Mailing Address
Average earning per week
$
City
State
Zip Code
Employer’s name and mailing address
Is residence address the same as mailing address?
Yes No If no, list residence address:
Do you have children/dependents under 18 years old and/or who
are disabled that don’t live with you? Yes No
If yes, list names and addresses of the dependents not residing
with you.
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: Married Single Widowed Divorced Registered Domestic Partnership
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 signature and impression of seal or stamp are required. RCW 42.44.090(1)
Subscribed and sworn to before me this date
Notary Seal or Stamp
Notary public signature
For the state of
Residing at
Title
My commission expires
RESET
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Pension Benefits PO Box 44281 Olympia WA 98504-4281 (Washington)

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Completed 23 June 2022

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