Form F242-420-000 "Declaration of Entitlement for Surviving Spouse or Registered Domestic Partners Benefits Under Industrial Insurance" - Washington

What Is Form F242-420-000?

This is a legal form that was released by the Washington State Department of Labor and Industries - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2017;
  • The latest edition provided by the Washington State Department of Labor and Industries;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form F242-420-000 by clicking the link below or browse more documents and templates provided by the Washington State Department of Labor and Industries.

ADVERTISEMENT
ADVERTISEMENT

Download Form F242-420-000 "Declaration of Entitlement for Surviving Spouse or Registered Domestic Partners Benefits Under Industrial Insurance" - Washington

1111 times
Rate (4.4 / 5) 55 votes
Department of Labor and Industries
Date
Claim No.
Folio No.
Pension Benefits
PO Box 44281
Olympia WA 98504-4281
Declaration of Entitlement
For Surviving Spouse or Registered Domestic
Partners 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.
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
Do you 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
Mailing Address
with you.
City
State
Zip Code
Is residence address the same as mailing address?
If there has been a change in dependency circumstances for any
No If no, list residence address:
Yes
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 marital/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:
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 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
F242-420-000 Declaration of Entitlement – Surviving Spouse or Registered Domestic Partnership 04-2017
RESET
Department of Labor and Industries
Date
Claim No.
Folio No.
Pension Benefits
PO Box 44281
Olympia WA 98504-4281
Declaration of Entitlement
For Surviving Spouse or Registered Domestic
Partners 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.
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
Do you 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
Mailing Address
with you.
City
State
Zip Code
Is residence address the same as mailing address?
If there has been a change in dependency circumstances for any
No If no, list residence address:
Yes
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 marital/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:
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 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
F242-420-000 Declaration of Entitlement – Surviving Spouse or Registered Domestic Partnership 04-2017
RESET