California Code of Regulations
Title 8 - Industrial Relations
Division 1 - Department of Industrial Relations
Chapter 4.5 - Division of Workers' Compensation
Subchapter 1 - Administrative Director-Administrative Rules
Article 1.5 - Receipt of Salary by Workers' Compensation Administrative Law Judge
Section 9714.5 - Affidavit

Department of Industrial Relations

Division of Workers' Compensation

Workers' Compensation Appeals Board

AFFIDAVIT(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 ____________________ (Date), 20_____ (Year). Executed on ____________________(Date) at ______________________________ (City), California. I declare under penalty of perjury that the foregoing is true and correct.

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).
3. Governor Newsom issued Executive Order N-63-20 (2019 CA EO 63-20), dated May 7, 2020, which extended certain deadlines related to the filing of Workers' Compensation decisions, due to the COVID-19 pandemic.

Note: Authority cited: Section 133, Labor Code. Reference: Sections 123.5(a) and 5313, Labor Code.