Form Ldol-Wc-1005a - Office Of Worker'S Compensation
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1STATE OF LOUISIANA
DEPARTMENT OF LABOR
OFFICE OF WORKERS' COMPENSATION
*
SS#:
*
DOCKET NO:
VERSUS
*
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
LDOL-WC-1005A
Rev. 1/98
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