Louisiana Administrative Code
Title 40 - LABOR AND EMPLOYMENT
Part I - Workers' Compensation Administration
Subpart 3 - Hearing Rules
Chapter 66 - Miscellaneous
Subchapter E - Forms
Section I-6635 - Request for Social Security Benefits Information ; Form LDOL-WC-1004
Current through Register Vol. 50, No. 9, September 20, 2024
REQUEST FOR SOCIAL SECURITY BENEFITS INFORMATION
(L.R.S. 23:1225)
DATE_______________________________________
NAME______________________________________ SSN____________________________________________
Please provide information concerning the referenced worker.
______________________________________________
Workers' Compensation Judge
Type of Social Security Benefit: _____ Disability _____ Retirement _____ Other _____ None
Current Social Security Benefit Paid to Employee ..................................................................................................................... $________________
Number of Auxillaries/Dependants on Record ......................................................................................................................... #________________
Age of Youngest Auxillary/Dependant ................................................................................................................................. ________________
PART I - CALCULATION OF INITIAL OFFSET
Date of Entitlement __________________
1. Original 80 Percent Average Current Earnings (ACE) on Record ........................................................................................... $________________
2. Total Family Benefit (TFB) ..................................................................................................................................................... $________________
3. Higher of Amounts Shown Above ............................................................................................................................................ $________________
4. Monthly Workers' Compensation (WC) Rate
(Subject to reduction due to allowable expenses)......................................................................................................................... $________________
5. Social Security Benefits Payable After Offset in Month of Entitlement
(#3 minus #4, if a negative amount show 0)............................................................................................................................... $________________
6. Original Federal Offset Amount (#2 minus #5).......................................................................................................................... $________________
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
PART II - CHANGE IN FEDERAL OFFSET AMOUNT DUE TO TRIENNIAL REDETERMINATION OF THE ACE (42 USC 424(F) (1) and 20 CFR 404.408(1))
Effective January ___________________
1. Redetermined 80 Percent ACE ................................................................................................................................................. $________________
2. Original 80 Percent ACE ......................................................................................................................................................... $________________
3. Difference Between Original and Redetermined ACE (#2 minus #1)......................................................................................... $________________
4. Cost of Living Allowance (COLA) Increases for Same Period of Time (Date of Entitlement Through
Date of Redetermination .......................................................................................................................................................... $________________
5. Decrease in Offset (#3 minus #4; if negative, show 0)............................................................................................................... $________________
6. Federal Offset Amount (#6 in Part I minus #5)......................................................................................................................... $________________
The next Triennial Redetermination of the ACE should be completed in ..................................................................................................... ___/___/___
PREPARED BY: _____________________________________________
Social Security Field Office
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1310.1.
**NOTE from the Office of the State Register: The backside of this form (LDOL-WC-1004) was not included on the disk. This form will need to be scanned or obtained from the agency.
