PETITION TO TERMINATE BENEFIT ENTITLEMENT STATE OF MAINE WORKERS' COMPENSATION BOARD 27 STATE HOUSE STATION AUGUSTA, MAINE 04333-0027 EMPLOYEE EMPLOYER NAME: STREET/P.O. BOX: CITY, STATE, ZIP: TELEPHONE NUMBER: NAME: STREET/P.O. BOX: DATE OF BIRTH: INSURER SOCIAL SECURITY NUMBER: XXX-XX- (only last four digits required) BOARD FILE NUMBER: NAME: STREET/P.O. BOX: CITY, STATE, ZIP: NOTICE If your benefit entitlement ends and you are experiencing extreme financial hardship due to inability to return to gainful employment, you may be eligible for an extension of your weekly benefits. To request such an extension, you must file a SIGNATURE OF PETITIONER FILING INSTRUCTIONS 1. Mail original petition to the Workers222 Compensation Board at the above address by regular mail. 2. Mail one (1) copy by certified mail, return receipt requested to each other party named in the petition. 3 . Keep one (1) copy for yourself and keep the green certified mail cards when returned to you by the U.S. Post Office. MONTH DAY YEAR 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 American LegalNet, Inc. www.FormsWorkFlow.com