Get Form 444

Filling out Form 444, the declaration of entitlement for totally disabled worker benefits under industrial insurance, is an important step for individuals seeking to maintain their benefits. This guide provides clear instructions to assist users in completing the form accurately and efficiently while filing online.

Follow the steps to complete Form 444 online.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by entering the date at the top of the form, followed by your claim number and folio number, which can typically be found on previous correspondence from the Department of Labor and Industries.
3. In the section labeled 'Print name of totally disabled worker', clearly write your full name as it appears on official documents.
4. Indicate whether you have worked since your last declaration by selecting 'Yes' or 'No'. If you select 'Yes', provide the date you began working, the number of days worked each week, and your average earnings per week.
5. Enter your complete mailing address, including street, city, state, and ZIP code. Confirm that your residence address is the same as your mailing address by checking the appropriate box.
6. If applicable, provide your employer's name and their mailing address. Specify if you have children or dependents under 18 who do not reside with you and list their names and addresses if so.
7. Report any changes in the status of dependents or children, as these changes may affect your monthly benefit.
8. Answer the criminal conviction question. If 'Yes', indicate when and where the conviction occurred.
9. Indicate if your marital or registered domestic partnership status has changed since the last declaration. Provide the date and nature of this change if applicable.
10. Fill in your social security number and phone number as required in the designated fields.
11. Sign the form in the signature block. If you are signing on behalf of someone else, provide a copy of the power of attorney document if not already submitted.
12. Have the document notarized by a notary public, who will provide their signature and impression of their seal or stamp. Ensure that the notary details are filled out, including their title and commission expiration date.
13. Once all sections are completed, you can save your changes, download the form, print it out, or share it as needed to return to the appropriate department.

Now that you have guidance on filling out Form 444, proceed to complete your documents online.