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-6637 - Motion for Recognition of Right to Social Security Offset ; Form LDOL-WC-1005A

Universal Citation: LA Admin Code I-6637
Current through Register Vol. 50, No. 9, September 20, 2024

Attached hereto and designated as "Attachment Number 5."

STATE OF LOUISIANA

DEPARTMENT OF LABOR

OFFICE OF WORKERS' COMPENSATION

__________________________________________________________ * SS#:

VERSUS * DOCKET NO:________________________

___________________ * DISTRICT:

MOTION FOR RECOGNITION OF RIGHT TO SOCIAL SECURITY OFFSET

NOW INTO COURT as undersigned comes ______________________________________________, employer/insurer in the referenced case, and requests the Workers' Compensation Judge to enter an order recognizing its right to take the reverse offset, since the claimant in this matter is receiving permanent total disability benefits under the Louisiana Workers' Compensation Act in addition to benefits under 42 U.S.C. Chapter 7, Subchapter II, entitled Federal Old Age, Survivors, and Disability Insurance Benefits.

SIGNED this the day of , 20__.

__________________________

(PRINT NAME)

Agent for _________________

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1310.1.

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