This verification form is the one-page Verification that the California Division of Workers' Compensation (DWC) publishes for a Petition for Benefits for Serious and Willful Misconduct of Employer Pursuant to Labor Code Section 4553. The petitioner signs it to state that they have read the petition, know its contents and declare under penalty of perjury that it is true and correct. On FillingPDF you can fill out the form online and download or print the completed PDF. The DWC publishes the original PDF on its website at dir.ca.gov.
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What is Verification Form: Serious and Willful Misconduct Petition?
The Verification is a one-page California Division of Workers' Compensation (DWC) form in which a petitioner confirms, under penalty of perjury, that the contents of a Petition for Benefits for Serious and Willful Misconduct of Employer Pursuant to Labor Code Section 4553 are true.
The printed text works as a sworn statement. The signer says they are a party to the action, that they have read the foregoing petition and know its contents, and that the contents are true of their own knowledge. The only exception is for matters the petition states on information or belief, which the signer says they believe to be true. The form then declares under penalty of perjury that the foregoing is true and correct.
The form has four entries: the county, the signer's capacity as a party, the date and place of signing (the place line ends with "California"), and the signature line, which is labeled Petitioner. The state is printed as STATE OF CALIFORNIA. The revision date printed on the form is April 2014.
The Verification does not request a benefit or start a claim. It is not a stand-alone filing: its wording refers to "the foregoing" petition, and it names that specific petition, so it is not a general-purpose verification for other petitions. The DWC lists its forms, with instructions on fillable versions, on its forms page at https://www.dir.ca.gov/dwc/forms.html.
Who needs to file Verification Form: Serious and Willful Misconduct Petition?
The petitioner who files a Petition for Benefits for Serious and Willful Misconduct of Employer Pursuant to Labor Code Section 4553 signs this Verification. The form's text has the signer say they are "a party to this action", and its only signature line is labeled Petitioner.
Points that follow from the printed form:
- The statement covers one document: the petition named in the form. Do not use it to verify a different petition, because the wording identifies this one.
- The signer declares that they have read the petition and know its contents, so the person who signs must be someone who can truthfully make that statement.
- The capacity line asks you to state in what role you are a party to the action.
- The form has no block for a representative, attorney or agent, and none for a notary. It does not say that anyone may sign on the petitioner's behalf.
If you are unsure whether you must file a petition under Labor Code Section 4553, or who may sign for a petitioner, the form does not answer that. Ask the DWC; it publishes the form and invites questions at [email protected].
When to file Verification Form: Serious and Willful Misconduct Petition
You complete the Verification when you complete the petition it verifies. The form refers to "the foregoing" Petition for Benefits for Serious and Willful Misconduct of Employer Pursuant to Labor Code Section 4553, so it goes with that petition and follows the petition's timing. The form prints no separate due date.
Sign only after you have read the petition in its final form, because by signing you state that you have read it and know its contents. Enter the date you actually sign on the "Executed on" line, together with the city where you signed it. If the petition is revised after you have signed, the Verification you signed describes the earlier text, so check that the two still match before the package is submitted.
Documents you need
- The Petition for Benefits for Serious and Willful Misconduct of Employer Pursuant to Labor Code Section 4553: the Verification refers to it as "the foregoing" petition and is completed with it.
How to fill out Verification Form: Serious and Willful Misconduct Petition
Get the form and the petition
Open the DWC's Verification PDF and have the Petition for Benefits for Serious and Willful Misconduct of Employer Pursuant to Labor Code Section 4553 beside you; the form verifies that petition.
Enter the county
On the line after "County of" under STATE OF CALIFORNIA, type the name of the county.
State your capacity as a party
On the line in "I, the undersigned, say that I am ____, a party to this action", enter your role as a party to the action.
Read the petition before signing
The printed text says you have read the foregoing petition and know its contents. The statement is true of your own knowledge, except for matters the petition states on information or belief, which you believe to be true.
Enter the date of signing
On the "Executed on" line, enter the date you sign the form.
Enter the city where you sign
On the line after "at", enter the city where you sign. The word "California" is already printed after it.
Sign on the Petitioner line
Sign above the word Petitioner. By signing, you declare under penalty of perjury that the foregoing is true and correct.
Review and download the PDF
Check the county, capacity, date and city, then download or print the completed PDF from FillingPDF and keep it with the petition it verifies.
How to submit Verification Form: Serious and Willful Misconduct Petition
The Verification prints no filing address, portal, fee or delivery rule of its own. It is the verification that follows the petition it refers to, so it goes through whatever channel the Petition for Benefits for Serious and Willful Misconduct of Employer Pursuant to Labor Code Section 4553 is filed through.
- Signed with the petition: complete the form, sign it on the Petitioner line and keep it with the petition it verifies.
- Where to get the form: the California Division of Workers' Compensation (DWC) publishes it at https://www.dir.ca.gov/dwc/FORMS/Seriousandwillful%20-Verification.pdf. The DWC forms page, https://www.dir.ca.gov/dwc/forms.html, recommends downloading fillable forms to your desktop.
- Questions: the DWC forms page invites comments and questions at [email protected].
FillingPDF lets you fill out and download the PDF; submission follows the channels the petition itself uses.
Common mistakes to avoid
- Signing before reading the petition. The form states that you have read the petition and know its contents.
- Leaving the line "I am ____, a party to this action" blank instead of stating your capacity as a party.
- Omitting the county at the top, or the date and city on the "Executed on" line, which ends with "California".
- Submitting the form without a signature on the Petitioner line. The declaration under penalty of perjury needs it.
- Using this Verification for a petition other than the Petition for Benefits for Serious and Willful Misconduct of Employer Pursuant to Labor Code Section 4553, which is the only petition it names.
- Stating as personal knowledge facts the petition gives on information or belief. The form separates those two kinds of matters.
- Signing and then changing the petition, so the Verification no longer matches the petition it verifies.
Frequently asked questions
What is the verification form for a serious and willful misconduct petition?
It is a one-page California DWC form, titled Verification, on which the petitioner states under penalty of perjury that the contents of a Petition for Benefits for Serious and Willful Misconduct of Employer Pursuant to Labor Code Section 4553 are true. It is completed with that petition.
Who signs the Verification?
The petitioner. The form's only signature line is labeled Petitioner, and the text has the signer state that they are a party to the action. The form prints no separate block for a representative or attorney.
Does the Verification need to be notarized?
The form has no notary block. It relies on the signer's declaration under penalty of perjury that the foregoing is true and correct, together with the date and place of signing.
What do I write on the "I am ____, a party to this action" line?
Enter your capacity as a party to the action. The form does not give a list of choices, so state your role in the proceeding in which the petition is filed.
What does "information or belief" mean on this form?
The form says its contents are true of your own knowledge, except for matters the petition states on information or belief. Those matters you state that you believe to be true. Everything else in the petition you are vouching for as personally known.
When do I complete the Verification?
When you complete the petition it verifies. The form refers to the foregoing petition and prints no separate deadline, so its timing follows the petition. Sign only after you have read the final petition.
Where do I send the Verification?
The form names no address or portal of its own. It goes with the Petition for Benefits for Serious and Willful Misconduct of Employer Pursuant to Labor Code Section 4553, through the same channel as that petition.
Can I fill out the Verification 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 with the DWC or any court; you submit it with your petition.
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