The verification form is a one-page declaration published by the California Division of Workers' Compensation (DIR – DWC) in which a party states that a Petition for Commutation of Future Payments is true. The petitioner enters the county, the party's capacity, and the date and place of signing, then signs under penalty of perjury. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; the original PDF is published by the DWC at dir.ca.gov.
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What is Verification Form for Commutation Petition – California DWC?
The Verification form is the one-page declaration, issued by the California Division of Workers' Compensation (DIR – DWC), in which a petitioner states that they have read a Petition for Commutation of Future Payments and that its contents are true.
The text printed on the form works as a sworn statement. The signer says they are a party to the action, that they have read the foregoing Petition for Commutation of Future Payments and know its contents, and that the contents are true of their own knowledge. The only exception is for matters stated in the petition on information or belief, which the signer says they believe to be true. The form then adds a declaration under penalty of perjury that the foregoing is true and correct.
The form is dated April 2014 and has four blanks: the county in the State of California heading, the signer's capacity as a party, the date of execution, and the place in California where it is signed. The signature line below is labeled Petitioner.
This form is not the petition itself. It refers to the petition as the "foregoing" document, so it accompanies a Petition for Commutation of Future Payments and has no use on its own. The text refers to no other petition or filing.
Who needs to file Verification Form for Commutation Petition – California DWC?
The petitioner who files a Petition for Commutation of Future Payments in California and is a party to the action signs this verification. The signature line is labeled Petitioner, and the opening statement says the signer is "a party to this action".
Conditions that come from the wording of the form:
- The signer must have read the petition and know its contents, since the form states that the signer has done so.
- The signer declares the petition true under penalty of perjury, so the person who signs is the one who makes that statement.
- The form is written to verify a Petition for Commutation of Future Payments. Do not use it to verify a different document, because its text names only that petition.
The form has one signature line and says nothing about an attorney, guardian or other representative signing for the petitioner. Questions about who may sign for someone else should go to the DWC, which the agency's forms page invites at [email protected].
When to file Verification Form for Commutation Petition – California DWC
Complete this verification when you prepare the Petition for Commutation of Future Payments, because the form states that the signer has read the "foregoing" petition. It is signed after the petition is final, and the date you enter in the Executed on line is the date you sign. The form prints no separate due date of its own, so it is submitted with the petition whenever that petition is filed. For any deadline that governs the petition itself, check with the DWC.
How to fill out Verification Form for Commutation Petition – California DWC
Open the form and review the text
Open the Verification form in FillingPDF and read the printed declaration, which refers to the foregoing Petition for Commutation of Future Payments.
Enter the county
In the State of California heading, enter the county on the line after County of.
State your capacity as a party
On the line after I, the undersigned, say that I am, enter your capacity as a party to this action. The signature line below is labeled Petitioner.
Confirm you have read the petition
The form states that you have read the foregoing petition and know its contents. Make sure that is true before you continue.
Enter the date of execution
On the Executed on line, enter the date you sign the form.
Enter the place of signing
After at, enter the place where you sign; the form already prints ", California" after the blank.
Sign and download the completed PDF
Sign on the Petitioner line, check the county, date and place, then download or print the completed PDF from FillingPDF and include it with the petition.
How to submit Verification Form for Commutation Petition – California DWC
The form prints no mailing address, portal or other channel of its own. Because it refers to the "foregoing Petition for Commutation of Future Payments", it goes with that petition and is delivered the way the petition is filed. Sign the completed form on the Petitioner line before you include it. FillingPDF lets you fill out and download the PDF; submission follows the agency's channels for the petition.
Common mistakes to avoid
- Signing the verification before reading the Petition for Commutation of Future Payments; the form states that you have read it and know its contents.
- Using this form to verify a document other than a Petition for Commutation of Future Payments, the only petition its text names.
- Leaving the County blank in the State of California heading.
- Leaving the "I am" blank empty instead of entering your capacity as a party to the action.
- Not entering the date and the California place in the Executed on line.
- Submitting the form unsigned; the declaration under penalty of perjury needs the signature on the Petitioner line.
- Signing as petitioner when you are not a party to the action, since the form says the signer is a party.
Frequently asked questions
What is a verification form for a Petition for Commutation of Future Payments?
It is a one-page declaration issued by the California Division of Workers' Compensation in which the petitioner states that they read the Petition for Commutation of Future Payments, that its contents are true, and that this is declared under penalty of perjury.
Who signs the Verification form?
The petitioner signs. The form says the signer is a party to the action, and the signature line is labeled Petitioner. It prints no line for an attorney or other representative to sign in the petitioner's place.
What do I write after "I, the undersigned, say that I am"?
Enter your capacity as a party to the action. The form does not list choices, but its signature line is labeled Petitioner, so the signer is the person who filed the Petition for Commutation of Future Payments.
Can I use this form to verify a different petition?
No. The printed text says the signer has read the foregoing Petition for Commutation of Future Payments and names no other document, so it is written for that petition only.
What goes on the "Executed on" line?
Enter the date you sign the form, then the place in California where you sign it. The form already prints "California" after the place blank, so you enter only the city or locality.
Where do I send the Verification form?
The form prints no address or channel. It refers to the foregoing petition, so it goes with the Petition for Commutation of Future Payments and is delivered the way that petition is filed. Contact the DWC for filing details.
Can I fill out the Verification form online on FillingPDF?
Yes. You can fill out the fillable PDF online on FillingPDF and download or print it. FillingPDF is an independent service, is not affiliated with the DWC and does not file the form; you submit it through the agency's channels.
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