This verification form is the sworn statement that goes with a Petition to Reopen in California workers' compensation matters. It is published by the CA Division of Workers’ Compensation (DIR – DWC). The petitioner, as a party to the action, states that the petition has been read and that its contents are true, 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 Petition to Reopen – California DWC?
The Verification, the DWC form that accompanies a Petition to Reopen, is a short sworn statement in which the petitioner, as a party to the action, declares under penalty of perjury that the petition is true and correct.
The text printed on the form works in four parts. First, it names the county under the heading "State of California." Second, the signer says what capacity they hold as "a party to this action" and confirms having read the foregoing Petition to Reopen and knowing its contents. Third, the signer states that the contents are true of their own knowledge, except for matters the petition states on information or belief, which the signer believes to be true. Fourth, the signer declares under penalty of perjury that the foregoing is true and correct, and records the date and the place in California where the statement was executed.
The form ends with a signature line labeled "Petitioner." The revision printed on it is April 2014. It is issued by the CA Division of Workers’ Compensation (DIR – DWC), which publishes it among its workers' compensation forms. It is not a petition itself: it verifies a separate Petition to Reopen and is wording that refers to that document only.
Who needs to file Verification Form for Petition to Reopen – California DWC?
The petitioner who signs a Petition to Reopen uses this form. The wording is written in the first person ("I, the undersigned") by a party to the action, and the signature line is labeled "Petitioner," so the person who brings the petition is the one who verifies it.
Points the form itself makes clear:
- The signer must have read the Petition to Reopen and know its contents before declaring it true.
- The signer may rely on information or belief for some matters, but only where the petition itself says so; everything else must be true of the signer's own knowledge.
- The signer declares under penalty of perjury, so the statement is made personally.
The text refers only to a Petition to Reopen. It is not worded for other kinds of filings, so do not use it to verify a different document. The form has no line for an attorney, agent or other representative to sign for the petitioner, and it prints no rule about who may sign on someone else's behalf.
When to file Verification Form for Petition to Reopen – California DWC
The verification is completed when the Petition to Reopen it refers to is completed, because it states that the signer has read "the foregoing" petition. It has no due date printed on it: it travels with the petition and is signed and dated at the time the petition is executed. The date you enter after "Executed on" should be the day you actually sign. Any deadline that applies to a Petition to Reopen is set by the rules for that petition, not by this form.
How to fill out Verification Form for Petition to Reopen – California DWC
Enter the county
On the line after "County of," write the county. The heading above it already reads "State of California."
State your capacity as a party
In the sentence "I, the undersigned, say that I am ____, a party to this action," write how you are a party to the action.
Confirm you read the petition
The printed text says you have read the foregoing Petition to Reopen and know its contents. Read the petition before you sign, since this statement is made about it.
Review the knowledge and belief statement
The form says the contents are true of your own knowledge, except matters the petition states on information or belief, which you believe to be true. There is nothing to enter here.
Read the penalty of perjury declaration
The line "I declare under penalty of perjury that the foregoing is true and correct" is printed on the form. Make sure it is accurate before you proceed.
Enter the date executed
After "Executed on," write the date you sign the verification.
Enter the place of execution
After "at," write the city where you sign. The word "California" is already printed after the blank.
Sign as Petitioner
Sign on the line above the label "Petitioner." The form has no other signature line.
Review and download the completed PDF
Check the county, capacity, date and place, then download or print the completed PDF from FillingPDF and keep it with the Petition to Reopen, as described under How to submit.
How to submit Verification Form for Petition to Reopen – California DWC
The form prints no address, portal or filing channel of its own. It verifies a Petition to Reopen, so it is submitted together with that petition, through whatever channel applies to the petition.
- With the petition: sign the verification and keep it with the Petition to Reopen it refers to, so the two are filed as one package.
- Agency forms page: the DWC lists its forms by subject at https://www.dir.ca.gov/dwc/forms.html, and questions about forms can be sent to [email protected], the address the DWC gives on that page.
FillingPDF lets you fill out and download the PDF; submission follows the channels that apply to the Petition to Reopen.
Common mistakes to avoid
- Signing the verification without having read the Petition to Reopen; the form states that the signer has read the petition and knows its contents.
- Leaving the county line blank under "State of California."
- Leaving the blank after "I am" empty instead of stating your capacity as a party to the action.
- Using the form to verify a document other than a Petition to Reopen; its wording refers to that petition.
- Omitting the date or the California place after "Executed on" and "at."
- Submitting the page unsigned; the signature line labeled Petitioner must be signed because the statement is made under penalty of perjury.
- Having someone other than the petitioner sign; the signature line is labeled Petitioner and the form has no line for a representative.
Frequently asked questions
What is a verification form for a Petition to Reopen?
It is a short sworn statement, published by the CA Division of Workers’ Compensation, in which the petitioner confirms having read a Petition to Reopen and declares under penalty of perjury that its contents are true and correct.
Who signs the verification form?
The petitioner signs. The wording is first person ("I, the undersigned") by a party to the action, and the signature line is labeled Petitioner. The form has no line for a representative to sign instead.
Can I use this verification form for something other than a Petition to Reopen?
No. The printed text says the signer has read the foregoing Petition to Reopen, so the form is worded for that document. Using it to verify a different filing would not match what the statement says.
Is there a deadline for the verification form?
The form prints no deadline of its own. It is signed when the Petition to Reopen it refers to is executed and goes with that petition, so timing follows the rules for the petition.
Where do I send the verification form?
The form names no address or portal. It verifies a Petition to Reopen, so it is submitted together with that petition through the channel that applies to the petition. The DWC lists its forms at dir.ca.gov/dwc/forms.html.
Can I fill out the verification form online?
Yes. You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is an independent service and does not file the form; you submit it with your Petition to Reopen through the agency's channels.
What do I write after "I am" on the verification?
Write your capacity as a party to the action, since the sentence reads "I, the undersigned, say that I am ____, a party to this action." The form gives no list of options, and the signature line is labeled Petitioner.
What does the date and place after "Executed on" mean?
They record when and where you signed the verification. Enter the date you sign and the city in California where you sign; the word California is already printed after the blank for the place.
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