Department of Industrial Relations
Division of Workers' Compensation
Workers' Compensation Appeals Board
(Labor Code Section 123.5(a))
I, __________________, (Name) Workers' Compensation Administrative Law Judge in the ____________________ (City) office of the Division of Workers' Compensation/Workers' Compensation Appeals Board, Department of Industrial Relations, State of California, declare that I have made a reasonable and diligent inquiry concerning those matters submitted to me, and based on information and belief, state that no cause remains pending and undetermined that has been submitted to me for the period of ninety (90) days prior to the first day of ____________________, 20__________. (Date) (Year)
Executed on ___________________________ at _________________,
California. I declare under penalty of perjury that the foregoing is true and correct.
Workers' Compensation Administrative Law Judge
Authority cited: Section 133, Labor Code. Reference: Sections 123.5(a) and 5313, Labor Code.
1. Amendment filed 1-12-99; operative 2-11-99 (Register 99, No. 3).
2. Amendment of section and new Note filed 5-23-2001; operative 6-22-2001 (Register 2001, No. 21).