Claimant Information Claimant Name First Name Last Name Address Street Address City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Postal Code Email Phone Docket Number(s) I am (age) years old Declaration I am the (check one) Claimant Other (relationship to the people in this case) Name and relation to claimant Please answer all of the following questions. Some of the questions may have been asked during the Employment Security Department’s investigation. Please answer the questions here, even if you answered the same questions before. 1. Did you provide the Employment Security Department with your true and correct name, date of birth, and social security number? Yes No 2. Did you provide the Department with true and accurate copies of your Driver’s License or State Identification Card, AND your Social Security Card? Yes No Date Provided If no, were there any circumstances that prevented you from providing the Department with identification documents? 3. Submit a copy of the following to this Declaration (even if you previously provided these documents to the Department): Driver’s License or State Identification Card; Social Security Card; and Passport (if you have one) Other form, such as Authorization to work or picture identification You may submit documents using the OAH Participant Portal, mail or fax. Please see www.oah.wa.gov for instructions or call (800) 583-8271. 4. Do you certify, under penalty of perjury, that the attached are true and correct copies of your identification documents? Yes No Provide any additional information that you would like the judge to consider: I declare under penalty of perjury under the laws of the state of Washington that the facts I have provided on this form are true. I agree. Submit
