Louisiana > Workers Comp
Motion For Recognition Of Right To Social Security Offset WC-1005A - Louisiana
| Motion For Recognition Of Right To Social Security Offset Form. This is a Louisiana form and can be used in Workers Comp . |
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STATE OF LOUISIANA LOUISIANA WORKFORCE COMMISSION 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 LWC-WC-1005A Rev. 7/08 American LegalNet, Inc. www.FormsWorkflow.com
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