Claim For Survivor'S Silicosis Benefits Form - State Of Montana - Department Of Labor & Industry

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State of Montana
Department of Labor & Industry
Judy Martz, Governor
Employment Relations Division
WC Regulation Bureau
Administration
BEFORE THE EMPLOYMENT RELATIONS DIVISION
OF THE MONTANA DEPARTMENT OF LABOR AND INDUSTRY
CLAIM FOR SURVIVOR'S SILICOSIS BENEFITS
I, _________________________________________, hereby submit a claim for silicosis
survivor's benefits based on Section 39-73-109 (1), MCA, which provides that upon the death of
a person receiving silicosis benefits, the surviving spouse, as long as such spouse remains
unmarried, is entitled to receive the payments granted to the deceased spouse. I understand I will
continue to receive these benefits as long as I remain unmarried or unless the Legislature were to
make a change.
I am the surviving spouse of ____________________________________, who was receiving
silicosis benefits when he passed away on ________________.
My social security number is ______________________. My date of birth is _____________.
(Provide your own social security number and birth date - not those of your deceased spouse).
I reside at (street address) ________________________________ in the City of
_____________________, County of ___________________, State of _______________.
Signed __________________________________ Date___________________
I hereby certify that on this ____________ day of _______________, 19___,
__________________________________________ has personally appeared before me, and
states under oath that the above statement is true and is made without reservation or concealment.
(SEAL)
___________________________________________________
Notary Public for the State of _____________________________________
Residing at______________________________________
My Commission Expires ___________________________
Phone (406) 444-6531
FAX (406) 444-3465
P.O. Box 8011
TDD (406) 444-5549
An Equal Opportunity Employer
Helena, MT 59604-8011

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