Free F242-382-000 letter of intent for school enrollment 03-2007 - Washington

Department of Labor and Industries Pension Benefits Section PO Box 44281 Olympia WA 95504-4281 Phone: (360) 902-5119 FAX: (360) 902-6455 Part A ­ To be completed by the student
Worker's Name Student's Name Student's address City Folio Number Phone

LETTER OF INTENT FOR SCHOOL ENROLLMENT

Claim Number Social Security # (For ID Only)

Check here if new address
State ZIP+4

Have you ever been incarcerated? If YES, when/where Have you ever been in the military? If YES, date:

Yes

No

To avoid an overpayment, I understand that I must notify the department immediately if my status as a FULL TIME student changes or if I become incarcerated or enlist in the military.
Date Signature of Student

Yes

No

PLEASE ANSWER THE FOLLOWING QUESTIONS: Do you plan on attending school as a full-time student at an accredited school during the summer? Yes Yes No No Do you plan on attending school as a full-time student at an accredited school in the fall? What school will you be attending?

If you will be attending a college, please send a copy of your letter of acceptance if you are a new student at that school.

I understand that if I receive pension benefits for the summer months and I do not return to school as a full-time student at an accredited school in the fall, I will be charged an overpayment for any pension benefits that have been paid during the summer and fall months.
BY MY SIGNATURE ABOVE, I DECLARE THE ABOVE STATEMENTS ARE TRUE.

F242-382-000 letter of intent for school enrollment 05-2007

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