Free I&A01.pmtplt copy - California

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NAME STREET CITY, STATE, ZIP CODE TELEPHONE #:

STATE OF CALIFORNIA

WORKERS' COMPENSATION APPEALS BOARD

WCAB#: Applicant, vs. APPLICATION FOR BENEFITS FOR SERIOUS AND WILLFUL MISCONDUCT OF EMPLOYER Defendants.

Proof Of Service By Mail I declare that: I am (resident of/employed in) the county of _______________ California. I am over the age of eighteen years, my (business/residence) address is: __________________________________________________________ __________________________________________________________ On ____________, I served the attached _______________________ on the ________________ in said case, by placing a true copy thereof enclosed in a sealed envelope with postage thereon fully paid, in the United State mail at _______________________________ addressed as follows ____________ __________________________________________________________ __________________________________________________________ I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct, and that this declaration was executed on (date) ___________________, at ________________ California. Type or print name _____________________________________ Signature ____________________________________________

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