FORM 87S 10/2017 PAGE 1 OF 2 MAIL TO:THE FULL COMMISSION NORTH CAROLINA INDUSTRIAL COMMISSION1236 MAIL SERVICE CENTER RALEIGH, NC 27699-1236 FORM 87S North Carolina Industrial Commission IC File # S TATEMENT OF ACCRUED ARREARAGES Emp. Code # G.S. 97-87(C )(1) Carrier Code # Emplo y er FEIN The I.C. File # is the unique identifier for this injury. It will be provided by return letter and is to be referenced in all future correspondence.. The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act I.C. No. ; , Employee, Plaintiff; v. , Employer; and Carrier; Defendants. PURSUANT TO N.C. Gen. Stat. 247 97-87, claimant hereby seeks the issuance of a Certificate of Accrued Arrearages and states as follows: 1. Claimant is entitled to monetary benefits from defendant(s) pursuant to: Please check appropriate box and provide filed date in blank. Opinion & Award Form 60 Form 21 Form 62 Form 26 Form 63 Other Order Specify Order and Filed Date 2. The following sums remain unpaid. Explain the basis for each sum, e.g. # weeks x comp rate after a specific date. An accrued arrearage requires that the time for making payment has expired. $ principal . Explain Calculation $ interest . Explain Calculation $ costs, etc. . Explain Calculation 3. As of the total accrued arrearage was $. Date of Application The undersigned hereby certifies that the above order or award is in full force and effect, that the time for making payment has expired and claimant is entitled to the sum stated in paragraph 3. Signature: Claimant Attorney Address Telephone American LegalNet, Inc. www.FormsWorkFlow.com FORM 87S 10/2017 PAGE 2 OF 2 MAIL TO:THE FULL COMMISSION NORTH CAROLINA INDUSTRIAL COMMISSION1236 MAIL SERVICE CENTER RALEIGH, NC 27699-1236 FORM 87S CERTIFICATE OF SERVICE This is to certify that I have this day served a copy of the foregoing Statement of Accrued Arrearages upon the below listed persons by depositing a copy of same in the United States mail, postage prepaid, addressed as follows: This the day of , 20. Signature Address Telephone Note: 97-87(c )(1) provides, in pertinent part: The claimant 205 shall serve a copy [of the Statement of Accrued Arrearages] on all parties against whom judgment is sought and their attorney of record. Note: 97-87(c ) provides: 1. Any party against whom judgment is sought may, within 15 days of the date of service of a Statement of Accrued Arrearages, file with the Commission proof of any payments that have been made or other responsive pleadings. 2. If no proof or other responsive pleading is filed within 15 days of the date of service of the Statement, the Commission shall immediately issue a Certificate of Accrued Arrearages. American LegalNet, Inc. www.FormsWorkFlow.com