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This is a California form that can be used for General within Workers Comp.
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CA DIR Lien Filing Fee Refund Request Department of Industrial Relations Office of the Director Attn: Lien and Reconciliation Unit LIEN REFUND REQUEST FILING DIRECTIONS: · Complete the form below, save and email to DWCLIEN@DIR.CA.GOV. · Please note that filing a request for refund does not guarantee a refund. · Lien resolution is not a basis for a refund. Lien fee reimbursement by defendant under LC 4903.07 is not a basis for a DIR refund. Name of Payer Payer Street Address City Payer Email Lien Reservation Number UAN Injured Worker Name Payment Type Reason for Refund Credit Card ACH First 6 and last 4 digits of card _____________ Lien Claimant Name Lien Amount ADJ Number Amount of Refund System Error Payment Confirmation No. State Payer Phone Zip Code Judge or Board Order (Attach order to refund request) Resubmission Incorrect Lien Fee Payment - same lien claimant - Correct ADJ or Lien No. _______________________ Incorrect Lien Fee Payment - different lien claimant - Correct ADJ or Lien No. ______________________ No Fee Required: Exempt LC § 4903(b) lien Duplicate Payment No Fee Required: Not a LC § 4903(b) or cost lien Other ____________________________________________________________ EXPLANATION please provide a detailed explanation describing the reason for your refund request. Please attach additional sheets as nesscary for explanantion and any required documents as noted above (i.e.: Judge Order, Reciept of payment, etc..) FORM A Version 1.0 FOR INTERNAL USE ONLY - Internal use ONLY Refund Request No. ____________ Today's Date: ____________ American LegalNet, Inc. www.FormsWorkFlow.com
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