Form Ldol -Wc-1004 - Request For Social Security Benefits Information - 1998

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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 . . . . . . . . . . . . . . . . . . . . . . . . . . . ___/___/___

PREPARED BY: _____________________________________________

Social Security Field Office

LDOL -WC-1004

REVISED 1/1/98