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 LWC -WC-1004 REVISED 7/8/08 American LegalNet, Inc. www.FormsWorkflow.com