GL01 (R. 02/2011 ) http://dwd.wisconsin.gov/wc/ Department of Workforce Development Dear Employee: You have requested an advancement of your permanent disability benefit or from a restricted account. Although payments are to be paid monthly, in emergency situations advances may be can be determined that this payment would be in the best interest of the injured worker and his or her dependents. To assist us in making this deter mination, you must provide us with all of the information requested on the financial statement on the back of this letter . In most cases, you can expect to receive a decision regarding your advance request within 10 days after we receive your completed fi nancial statement. It is important for you to know that in all cases where monthly unaccrued permanent disability benefits are being advanced by an insurance carrier or self - insured employer, there will be a 5 % interest credit allowed. This interest, comp ounded annually on the unaccrued benefits, will reduce the total compensation payable to you . Advancement checks will be made out in joint draft to you and the party to whom you are indebted. Advance requests and disputes over any decisions regarding thes e requests must be submitted in writing. Not all advance requests will be approved. No advancements will be granted on such items as credit card bills or personal loans. Under the Worker's Compensation Act, you are limited to three advance payments in a calendar year. Please send your completed financial statement to: Department of Workforce Development P.O. Box 7901 Madison, WI 53707 - 7901 American LegalNet, Inc. www.FormsWorkFlow.com ADVANCEMENT OR LUMP SUM REQUEST * Provision of your Social Security Number (SSN) is v oluntary . Failure to provide it may result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m) , Wisconsin Statutes]. WC Claim Number Employee Name Social Security Number * Da te of Injury Requester N ame ( if other than employee ) Requesting as Beneficiary due to work related fatality? Yes No Address (Number, Street, City, State and Zip Code) Date of Birth Marital Married Single Status: Separated Divorced Are you currently employed? Yes Employer Name Employer Phone Number ( ) Employer Address (Number, Street, City, State, Zip Code) Your gross salary or wages $ per Hours Per Week: Present income of injured (all sources) Social Security Benefits If spouse employed, enter gross wages: $ per Number of dependents under 18 years of age: Child Suppo rt Obligation: Savings: Property owned Estimated Value Amount of money (personal and real estate) owed on property To expedite our response, please give the amount and reason why advancement is requested. Be specifi c. Provide current copies of bills that are in arrears. Certified as correct by: (signature of injured employee) Signature Date Signed T elephone Number: ( ) Under the Worker's Compensation Act, you are limited to three advance payments in a calendar year. Return completed form to: - 7901 WKC-136 (R. 07/2017) Department of Workforce Development Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707 Telephone: (608) 266 - 1340 Fax: (608) 267 - 0394 http://www.dwd.wisconsin/wc e - mail: DWDDWC@dwd. wisconsin.gov American LegalNet, Inc. www.FormsWorkFlow.com