PETITION FOR REVIEW OF EXTENDED BENEFITS AWARDED DUE TO EXTREME FINANCIAL HARDSHIP PURSUANT TO 39-A M.R.S.A. §213(1)(B) STATE OF MAINE WORKERS' COMPENSATION BOARD 27 STATE HOUSE STATION AUGUSTA, MAINE 04333-0027 EMPLOYER NAME: STREET/P.O. BOX: CITY, STATE, ZIP: INSURER NAME: STREET/P.O. BOX: CITY, STATE, ZIP: SOCIAL SECURITY NUMBER: XXX-XX(only last four digits required) BOARD FILE NUMBER: NAME: STREET/P.O. BOX: CITY, STATE, ZIP: TELEPHONE NUMBER: EMPLOYEE 1. Compensation of $ 2. Since the order extending benefits dated employee's circumstances; specifically: per week is being paid for partial incapacity. MONTH DAY YEAR , there has been a material change in the THEREFORE, the petitioner asks the board to reduce/discontinue the employee's extended benefits pursuant to 39-A M.R.S.A. §213(1)(B). __________________________________________________________ SIGNATURE OF PETITIONER DATED: MONTH DAY YEAR FILING INSTRUCTIONS 1. 2. 3. Mail original petition to the Workers' Compensation Board at the above address by regular mail. Mail one (1) copy by certified mail, return receipt requested to each other party listed on the petition. Keep one (1) copy for yourself and keep the green certified mail cards when returned to you by the U.S. Post Office. NAME OF PETITIONER'S ATTORNEY OR ADVOCATE (IF ANY) STREET/P.O. BOX CITY, STATE, ZIP TELEPHONE NUMBER The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon request. For assistance with this form, contact the ADA Coordinator at the Maine Workers' Compensation Board. Telephone: (888) 801-9087 or TTY Maine Relay 711. WCB-213A (eff. 1/1/13) American LegalNet, Inc. www.FormsWorkFlow.com