COMPLETE THIS AFFIDAVIT AND RETURN TO:
Department of Labor and Industries Division of Insurance Services PO Box 44291 Olympia WA 98504-4291
AFFIDAVIT for TIME-LOSS COMPENSATION
Claim Number Name (Please Print)
Due to my work-related injury/illness, I didn't work and I wasn't able to work from ___________ to ____________. Check one box on each line to complete the statements below:
I have I have
have not have not
been self-employed during this period. performed any work, paid or unpaid, including but not limited to COPES or CHORE Services, or volunteer work, due to a work-related injury/illness. applied for or received unemployment benefits during this period. received Social Security benefits during this period. applied for or received benefits from DSHS during this period. been convicted of a crime and under sentence at any time during this period.
I have I have I have I have
have not have not have not have not
By signing below, I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct and further that: I understand that if I make a false statement about my activities or physical condition, I will be required to refund my benefits, and I may face civil or criminal penalties. I understand I must immediately contact my claim manager if I perform any work (paid or unpaid) , if my doctor releases me for work, if I am incarcerated and under sentence, if the custody of my children changes, and if I apply for or receive Social Security benefits or DSHS benefits.
Signature
MAILING Address RESIDENCE Address:
Date
City
State
ZIP
City
State
ZIP
Residence is the same as MAILING address:
Yes
No
F242-395-000 affidavit for time-loss compensation 01-2009