Form Dwc-Ad 10133.53 - Notice Of Offer Of Modified Or Alternative Work - State Of California Page 4

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NOTICE TO THE PARTIES
If the offer is not accepted or rejected within 30 days of receipt of the offer, the offer is deemed to be rejected by the
employee.
If a dispute occurs regarding the above offer or agreement, either party may request the Administrative Director to
resolve the dispute by filing a Request for Dispute Resolution (Form DWC-AD 10133.55) with the Administrative
,
Director
Division of Workers' Compensation, P.O. Box 420603, San Francisco, CA 94142-0603.
DWC-AD form 10133.53 (SJDB) Rev: 1/1/14 Page 4 of 4

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