REQUEST FOR SOCIAL SECURITY BENEFITS INFORMATION
(L.R.S. 23:1225)
DATE
NAME
SSN
Please provide information concerning the referenced worker.
Workers' Compensation Judge
Type of Social Security Benefit:
_____ Disability
Retirement
_____ Other
None
Current Social Security Benefit Paid to Employee
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Number of Auxillaries/Dependants on Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
#
Age of Youngest Auxillary/Dependant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PART I - CALCULATION OF INITIAL OFFSET
Date of Entitlement __________________
. . . . . . . . . . . . . . . . . . . . .
1. Original 80% Average Current Earnings (ACE) on Record
$
2. Total Family Benefit (TFB)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
3. Higher of Amounts Shown Above . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
4. Monthly Workers' Compensation (WC) Rate
(Subject to reduction due to allowable expenses) . . . . . . . . . . . . . . . . . . . . . . . . .
$
5. Social Security Benefits Payable After Offset in Month of Entitlement
(#3 minus #4, if a negative amount show 0) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
6. Original Federal Offset Amount (#2 minus #5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
PART II - CHANGE IN FEDERAL OFFSET AMOUNT DUE TO TRIENNIAL REDETERMINATION
OF THE ACE (42 USC 424 (F) (1) and 20 CFR 404.408(1))
Effective January ___________________
1. Redetermined 80% ACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
2. Original 80% ACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
3. Difference Between Original and Redetermined ACE (#2 minus #1) . . . . . . . . . . . . . . .
$
4. Cost of Living Allowance (COLA) Increases for Same Period of Time (Date of Entitlement
Through Date of Redetermination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
5. Decrease in Offset (#3 minus #4; if negative, show 0) . . . . . . . . . . . . . . . . . . . . . . . . . .
$
6. Federal Offset Amount (#6 in Part I minus #5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
The next Triennial Redetermination of the ACE should be completed in . . . . . . . . . . . . . . . . .
/
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PREPARED BY:
Social Security Field Office
LWC -WC-1004
REVISED 7/8/08