California Acknowledgement Form Pdf
- Law permits California Notaries to use an out-of-state acknowledgment form on a document that will be filed in that other state or U.S. Jurisdiction, but only if “the form does not require the Notary to determine or certify that the signer holds a particular representative capacity or to.
- State of California. County of Subscribed and sworn to (or affirmed) before me on this day of , 20, by, proved to me on the basis of satisfactory evidence to be the. Person(s) who appeared before me. (Seal) Signature A notary public or other officer completing this.
Concussion Policy Acknowledgment Form – A concussion is a type of head injury which is often acquired by athletes and extreme sports enthusiasts. Although a concussion is common and is known by sports participants, it is still important to avoid having any sort of injury, either before, during, or after the activity. The California notary acknowledgement forms are certificates verifying that a notary public has confirmed the identity of a person who signed a legal document.An individual seeking acknowledgement must appear before the notary public and present satisfactory.
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- Employer Pull Notice Program Requirements (PDF) (INF 1107)
- Application for Employer Pull Notice Account (PDF) (INF 1104)
More information about the INF 1104 form
- Commercial Employer Pull Notice Enrollment or Deletion of Drivers form and Instructions (PDF) (INF 1100)
More information about the INF 1100 form
- Authorization for Release of Driver Record Information (PDF) (INF 1101)
More information about the INF 1101 form
- Commercial or Government Employer Pull Notice Enrollment of Out-of-State Licensed Drivers form and Instructions (PDF) (INF 1102)
More information about the INF 1102 form
- Commercial Employer Pull Notice Requester Account Notice of Change form and Instructions (PDF) (INF 4)
More information about the INF 4 form
- Request for Closure of Employer Pull Notice Account form and Instructions (PDF) (INF 1112)
- Employer's Report of Medical Exam Failure/Request for Reexamination of Driver (PDF) DS524
More information about the DS524 form
- Government Employer Pull Notice (PDF) (INF 1103)
More information about the INF 1103 form
- Information Security Statement (PDF) (INF 1128)
More information about the INF 1128 form
- Request for Driver License/Identification Card Status and Record Information (PDF) (INF 1119)
More information about the INF 1119 form
- Employer Pull Notice Agent Authorization form (PDF) (INF 2110)
More information about the INF 2110 form
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Back to EPN main pageFillable form instructions = Fillable Adobe Acrobat form - en español = Adobe Acrobat for = Word form
Forms are grouped by relevant subject, then in alphabetical order. Use the arrows to change to reverse alphabetical order or search by form number. The ten most-downloaded forms also appear in the “Frequently used forms” section.
Frequently used forms
Form | Number |
---|---|
Request For QME panel under Labor Code Section 4062.1 - Unrepresented | QME 105 |
Replacement panel request | QME 31.5 |
Minutes of hearing | WCAB 20 |
Physician's return-to-work & voucher report | DWC - AD 10133.36 |
Pre-trial conference statement | WCAB 24 |
Workers' compensation claim form
| DWC 1 |
Supplemental job displacement non-transferable voucher * Injuries occurring on or after 1/1/13 | DWC - AD 1033.32 |
Medical mileage expense form English/Spanish - Word version * For travel on or after 1/1/19 | Mileage form |
Additional QME panel request | QME 31.7 |
Request For QME panel under Labor Code Section 4062.2 - Represented * injuries occurring prior to 1/1/05 | QME 106 |
Notice to Employees - Injuries caused by work - English and Spanish | DWC 7 |
Audit forms
Form | Number |
---|---|
DWC-AU-906 | |
Annual report of adjusting locations for claims administrators whose ARI requirements have been waived | DWC-857 |
Audit report of inventory | DWC-851 |
DWC-AU -905 |
Complaint forms
Form | Number |
---|---|
Complaint form: Utilization review - word version * Note: If you want to save this form to your computer and email it to the DWC Medical Unit, you MUST use the Word version. The PDF version cannot be saved to your computer once filled. | DWC UR 1 |
Report of suspected medical care provider fraud | DWC SMBFR 1115 |
Complaint form: Workers' Compensation Judge | |
Complaint form: Audit Unit | DWC-AU -905 |
Complaint form: Qualified medical evaluator (QME) | |
Complaint form: Medical Provider Network | DWC 9767.16.5 |
Court forms
Form | Number |
---|---|
Compromise and release - dependency claim | DWC-CA 10214-d |
Compromise and release - third party | DWC-CA 10214-e |
Declaration of readiness to proceed - expedited trial | DWC-CA 10208.3 |
Declaration of readiness to proceed | DWC-CA 10250.1 |
DWC-CA 10232.1 | |
Proof of service | |
Document separator sheet * click paperclip for document titles and document types
| DWC-CA 10232.2 |
Stipulations with request for award - death case | DWC-CA 10214-b |
Stipulations with request for award * For injury on or after 1-1-2013 | DWC-CA 10214-a |
Stipulations with request for award * For injury prior to 1-1-2013 | DWC-CA 10214-a |
Supplement to minutes of hearing | WCAB 20.1 |
Application for adjudication of claim * How to submit an amended application for adjudication of claim | WCAB 1 |
Answer to application for adjudication of claim | WCAB 10 |
Notice and request for allowance of lien | WCAB 6 |
Petition to terminate liability for temporary disability indemnity | WCAB 46 |
Arbitrator submittal | |
Request for accommodations by persons with disability | DWC 5 |
Addendum to application for adjudication of claim to identify legal entity employing injured worker | WCAB 2 |
Application for adjudication of claim - Death case | DIA 2 |
Application for benefits for serious and willful misconduct of employer
| |
Application for discrimination benefits pursuant to Labor Code section 132 - A
| |
DWC 3 | |
Declaration pursuant to Labor Code section 4906(h) | |
Minutes of hearing | WCAB 20 |
Minutes of hearing - addendum | WCAB 20.2 |
Notice of dismissal of attorney | DWC WCAB 37 |
Notice of employee death | DIA 510 |
Petition for appointment of guardian ad litem and trustee | DWC WCAB 8 |
Petition for change of primary treating physician | DWC 280 |
Petition for commutation of future payments
| DWC WCAB 49 |
Petition for reconsideration | DWC WCAB 45 |
Petition to reopen
| DWC WCAB 42 |
Pre-trial conference statement | WCAB 24 |
Pre-trial conference statement lien issues addendum | WCAB 24.1 |
Special notice of lawsuit | |
Substitution of attorneys | DWC WCAB 36 |
Verification | |
Compromise and release | DWC-CA 10214-c |
Information guidelines for submission of settlement documents | |
Subpoena Duces Tecum | DWC WCAB 32 |
Subpoena | DWC WCAB 30 |
Disability Evaluation forms
Form | Number |
---|---|
Employee's permanent disability questionnaire | DWC-AD 100 |
Request for consultative rating | DWC-AD 104 |
Request for reconsideration of summary rating by the administrative director | DWC-AD 103 |
Request for summary rating determination of Qualified Medical Evaluator's (QME) Report | DWC-AD 101 |
Request for summary rating determination - primary treating physician report | DWC-AD 102 |
Apportionment request | DEU 105 |
Commutation request | |
DEU 110 |
Employer forms
Form | Number |
---|---|
Workers' compensation claim form
| DWC 1 |
Employer's report of occupational injury or illness | DLSR 5020 |
Petition for permission to negotiate a section 3201.7 labor-management agreement | DWC RGS-1 |
Independent Bill Review forms
Form | Number |
---|---|
Provider's request for second bill review | DWC Form SBR-1 |
Request for independent bill review | DWC Form IBR-1 |
Independent Medical Review forms
Form | Number |
---|---|
Application for Independent Medical Review | DWC IMR |
Petition appealing administrative director’s independent medical review determination | |
* For injured workers who need to get an independent medical review | DWC 9768.10 |
Physician contract application * For doctors who want to become independent medical reviewers | DWC 9768.5 |
Lien forms
Form | Number |
---|---|
Lien filing fees refund request | Form A |
Lien conference disposition | WCAB 27 |
Medical forms
California Notary Acknowledgement Form Pdf
Form We just need to sustain it until the new system is ready.Here is some information I found on wikipedia. If you scroll down to the RemoteApp section, you'll see that it was not available until 2008 R2. Wrote:As I understand, prior to 2008 R2, Remote Desktop Services existed as Terminal Services. RemoteApp was not introduced until 2008 R2. Run 16 bit applications. | Number |
---|---|
Doctor's first report of occupational injury or illness | 5021 |
Official medical fee schedule order form | |
Physician's guide order form | |
Primary treating physician's permanent and stationary report * 2005 permanent disability rating schedule | DWC PR-4 |
Primary treating physician's permanent and stationary report | DWC PR-3 |
Primary treating physician's progress report | DWC PR-2 |
Medical mileage expense form English/Spanish - word version * For travel on or after 1/1/19 | Mileage form |
Request for authorization for medical treatment | 9785.5 |
Medical Provider Network forms
Form | Number |
---|---|
Cover page for medical provider network application or plan for reapproval | DWC 9767.4 |
Notice of medical provider network plan modification | DWC 9767.8 |
Complaint form: Medical Provider Network | DWC 9767.16.5 |
Petition for suspension or revocation of a medical provider network - Part A | DWC 9767.17.5 |
MPN response to petition for suspension or revocation of a medical provider network - Part B | DWC 9767.17.5 |
Pre-designation forms
Form | Number |
---|---|
DWC 9783.1 | |
DWC 9783 | |
Noticia de quiropráctico personal o acupuntor personal | DWC 9783.1 |
Designación previa de médico personal | DWC 9783 |
Public records forms
Number | |
---|---|
Request for public records | |
Request for authorization number form | DWC AD 3 |
QME/AME forms
Form | Number |
---|---|
Additional QME panel request | QME 31.7 |
AME or QME declaration of service of medical - legal report | QME 122 |
Application for accreditation or re-accreditation as education provider | QME 118 |
Application for appointment as qualified medical evaluator | QME 100 |
Course Evaluation for Administrative Director (QME) | QME 117 |
Declaration regarding protection of mental health record | QME 121 |
Faculty disclosure of commercial interest | QME 119 |
QME appointment notification form | QME 110 |
QME disclosure of specified financial interests | QME 124 |
QME notice of unavailability | QME 109 |
QME or AME conflict of interest disclosure form and objection or waiver | QME 123 |
QME/AME report time frame extension request | QME 112 |
Qualified medical evaluator's findings summary form - unrepresented cases only | QME 111 |
Reappointment application as qualified medical evaluator | QME 104 |
Registration for QME competency examination | QME 102 |
Replacement panel request | QME 31.5 |
Proof of service: Represented additional panel | |
Proof of service: Represented replacement panel | |
Request for Factual Correction of a Unrepresented Panel QME Report | QME 37 |
Request For QME panel under Labor Code Section 4062.1 - Unrepresented | QME 105 |
Solicitud De Panel De Evalua dor Medicó Calificado- Empleado sin representación legal | QME 105 |
Request For QME panel under Labor Code Section 4062.2 * For injuries occurring prior to 1/1/05 Represented * Note: For injuries on or after 1/1/05, online only as of Oct. 1, 2015. No paper submissions postmarked after Sept. 3, 2015. | QME 106 |
Proof of service: Unrepresented additional QME panel | |
Proof of service: Unrepresented replacement panel | |
Voluntary directive for alternate service of medical-legal evaluation report on disputed injury to psyche | QME 120 |
Complaint form: Qualified medical evaluator (QME) |
SIBTF/UEBTF forms
Form | Number |
---|---|
Application for discretionary payments from the uninsured employers' fund | DWC-UEF 50 |
Application for subsequent injuries fund benefits |
Supplemental Job Displacement Benefits forms
California Acknowledgement Form Pdf Free
Form | Number |
---|---|
Description Of Employee's Job Duties | DWC - AD 10133.33 |
Notice of Offer of Regular Work * Injuries occurring between 1/1/05 - 12/31/12, Inclusive | DWC - AD 10118 |
Supplemental Job Displacement Non-Transferable Voucher * Injuries occurring on or after 1/1/13 | DWC - AD 10133.32 |
Notice of Offer Of Regular Modified Or Alternative Work * Injuries occurring on or after 1/1/13 | DWC - AD 10133.35 |
Physician's Return-to-Work & Voucher Report | DWC - AD 10133.36 |
Notice Of Offer Of Modified Or Alternative Work * Injuries occurring between 1/1/04 - 12/31/12 | DWC - AD 10133.53 |
Request for Dispute Resolution Before Administrative Director Instructions - Instrucciones | DWC - AD 10133.55 |
Supplemental Job Displacement Nontransferable Training Voucher * Injuries occurring between 1/1/04 - 12/31/12 | DWC - AD 10133.57 |
Comments? Questions? Suggestions? Email dwc@dir.ca.gov
September 2016