Petition For Commutation Of Future Payments

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STATE OF CALIFORNIA
Department of Industrial Relations
Division of Workers' Compensation
WORKERS' COMPENSATION APPEALS BOARD
)
Case No.
)
Petition for Commutation
)
Applicant
)
of Future Payments
)
vs.
)
)
)
NOTICE: Order may issue granting petition for commutation unless
objection is filed within (10) days after date of service
)
Defendants
)
1. Applicant requests
(A) that all future payments be commuted to a lump sum.
(B) that sufficient final weekly payments be commuted to produce the sum of $________
(Strike out part not applicable)
2. The reason for requesting commutation is:
NOTE: Good cause must be shown under Labor Code Section 5100. No attorney fee will be allowed unless Requested.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Dated:____________________________
Petitioner
Copies mailed to the following on
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
19
Attorney for Petitioner
ORDER
COMMUTATION IS HEREBY ORDERED AS FOLLOWS:
Dated: ________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
WORKERS’ COMPENSATION JUDGE
Served by mail on persons shown on
the official address record
By: __________________________________
DWC/WCAB FORM 49 (REV. 11-74)

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