APPLICATION FOR MEDIATION OR HEARING 227 FORM C Add other employer and date(s) of injury Petition to stop weekly benefits(Provide explanation below and attach affidavit of payment) Petition to fix fees(Provide explanation below) Petition to recoup(Provide explanation below) Add Funds(Specify name of Fund and provision of Act below) Petition to determine rights; e.g., dependency, AWW, etc. () Other(Provide a brief explanation of the issues below) Non-cooperation with vocational rehabilitation (Provide explanation below) P- American LegalNet, Inc. www.FormsWorkFlow.com