Date Employee Address City, State, Zip Date of Injury Claims Administrator Address City, State, Zip Telephone Number Claim Number Employer NOTICE REGARDING VOCATIONAL REHABILITATION MAINTENANCE ALLOWANCE (Claims Administrator's Name) is handling your workers' compensation claim on behalf of (Employer). This notice is to advise you of the status of vocational rehabilitation maintenance allowance payments for your workers' compensation injury of . Only the items completed below concern your benefits at this time. Payments are the period from beginning being resumed for vocational rehabilitation maintenance allowance for through . The first payment is enclosed sent separately. Your weekly maintenance allowance rate is based on your earnings of $ per week. Payments will be sent to you every two weeks on and will continue until further notice. $ Attorney fees at the rate of $ as requested by your attorney. per week are withheld from your maintenance allowance You may have the option of receiving a permanent disability supplement to increase the maintenance allowance payments to the temporary disability rate. Payments include a permanent disability supplement of $ per week as you requested. Payments are ending because Benefits paid to you total $ at $ for the period from per week. through Please see the attached for (additional) periods paid. Additionally, permanent disability supplements totalling $ Included in this amount is an overpayment totalling $ overpayment against have been paid. . We assert credit for the . 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, call me at . Sincerely, , Claims Examiner Enc.: Payment Record cc: Applicant's Attorney DWC 500-M Employee Claim Form 3/96 2002 © American LegalNet, Inc.