California Regulations 9714.5
From Wcc
§ 9714.5 Affidavit
| Department of Industrial Relations
Division of Industrial Accidents Workers' Compensation Appeals Board AFFIDAVIT (Labor Code Section 123.5) I, _________, (Name) Workers' Compensation Administratiave Law Judge in the _________ ______ (City) office of the Division of Industrial Accidents/Workers' Compensation Appeals Board, Department ofIndustrial Relations, State of California, declare that I have personal knowledge that nocause remains pending and undetermined that has been submitted to me for the period of ninety(90) days prior to the first day of ______ (Date), 19___ (Year). Executed on _________ (Date) at _________ (City), California. I declare under penalty of perjurythat the foregoing is true and correct. _________ (Signature) Workers' Compensation Administrative Law Judge
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