Date Employee Address City, State, Zip Date of Injury Claims Administrator Address City, State, Zip Telephone Number Employer Claim Number INTENT TO WITHHOLD VOCATIONAL REHABILITATION MAINTENANCE ALLOWANCE (Claims Administrator's Name) is handling your workers' compensation claim on behalf of (Employer). You have been receiving a vocational rehabilitation maintenance allowance of $ per week during your participation in vocational rehabilitation services. We intend to stop these payments on (date) participate in vocational rehabilitation services by because you have unreasonably failed to . assert a credit against future benefits in the amount of $ through . for the period from If you disagree with this decision, you may request a conference with the State Rehabilitation Unit to resolve this dispute. YOU HAVE TEN (10) DAYS FROM THE DATE YOU RECEIVE THIS NOTICE TO MAKE THIS REQUEST. Enclosed is a Request for Dispute Resolution (Form RU 103) and a Case Initiation Document (Form RU 101). These are the forms used to request a conference. There are instructions at the top of each form which describe how to complete them. The completed forms should be sent to the nearest State Rehabilitation Unit. The State of California requires that you be given the following information: If you disagree with the decision, you may receive recorded information by calling the State Information and Assistance Office at 1-800-736-7401 or call your local Information and Assistance Officer at . You may also consult with and be represented by an attorney, or you may ask to have your case heard by the State Rehabilitation Unit. If you have questions, please call me at . Sincerely, , Claims Examiner Enc.: Help in Returning to Work Case Initiation Document (Form RU-101) Request for Dispute Resolution (Form RU-103) cc: Applicant's Attorney DWC 500-N Help in Returning to Work - '94 3/96 2002 © American LegalNet, Inc.