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-6639 - Order Recognizing Right to Social Security Offset ; Form LDOL-WC-1005B

Attached hereto and designated as "Attachment Number 6".

STATE OF LOUISIANA

DEPARTMENT OF LABOROFFICE OF WORKERS' COMPENSATION

_________________ * SS#:

VERSUS * DOCKET NO:____________________________

____________ * DISTRICT:

ORDER RECOGNIZING RIGHT TO SOCIAL SECURITY OFFSET

This matter is before the Workers' Compensation Judge on the motion of the employer/insurer for recognition of its right to claim the Social Security reverse offset in this case. The Workers' Compensation Judge finds that the claimant is receiving permanent total disability benefits under the provisions of 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. The Workers' Compensation Judge further finds the under that provisions of L.R.S. 23:1225(A) the employer/insurer has claimed and is entitled to a reduction in the Workers' Compensation benefits paid to claimant in the amount of.

IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that the employer/insurer is hereby allowed to offset the Workers' Compensation benefits paid to claimant in the amount of __________, beginning on _______, 20____, the date of employer/insurer's judicial demand.

IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the Social Security Administration reverse its Social Security offset effective _______, 20_____, the date of employer/insurer's judicial demand.

READ, RENDERED AND SIGNED this the ________ day of __________, 20 ___ at __________________ Parish, Louisiana.

___________________________________

WORKERS' COMPENSATION JUDGE

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