Dwc District Office California Form Pack Page 18
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VERIFICATION
STATE OF CALIFORNIA
your county
County of ___________________________________________
your name
I, the undersigned, say that I am ________________________________________, a party to
this action. I have read the foregoing Petition to Reopen and know the contents thereof, and that
the same is true of my own knowledge, except as to the maters which are therein stated upon my
information or belief, and as to those matters that I believe to be true.
I declare under penalty of perjury that the foregoing is true and correct.
date mailed
your city
Executed on _____________________ at __________________________________, California.
your signature
__________________________________________
Petitioner
April 2014
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