WKC - 6119 (R. 06/2017 ) SOCIAL SECURITY REVERSE OFFSET WORKSHEET * Provision of your Social Security Number (SSN) is voluntary. 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]. Employee: Injury Date: Insurer: Date of Birth: Social Sec. No * : File Number: 1. Initial 80% ACE: $ 2. Index: X 3. Redetermined 80% ACE: $ X 12/52 = $ 4. Weekly WC before offset: $ 5. Limit ( Higher of 3 or 4): $ 6. Initial MBA: X 12/52 = $ 7. Weekly balance to employee: $ 8. Entitlement date: 9. Effective date of computation: Instructions - Line 1: Enter 80% . not reduce the ACE to 80%; the figure has already been reduced. Line 2: Enter the index based on the entitlement date and redetermination chart. Line 3: Multiply Line 1 by Line 2 to find the r edetermined ACE. Multiply the monthly amount by 12/52nds to find the weekly amount. If indexing is not required use same figure as in Line 1. Line 4: Enter the WC otherwise due. This rate may be for TTD, escalated TTD, TPD, PTD, or PPD. Vocational rehabil itation is not offset. Line 5: Enter the top limit. This amount will be the higher of Line 3 (redetermined ACE) or the WC rate otherwise payable from Line 4. Line 6: . BA by 12/52nds to find the weekly amount. Line 7: Subtract Line 6 from Line 5 to find the weekly balance to employee. This amount is the total amount the insurance carrier is obligated to pay. If this line is greater than Line 4 then no offset can be take n. Line 8: Enter the entitlement date. Line 9: Enter the effective date of this computation. This date is the first date that the insurance carrier can take this offset. Department of Workforce Development mpensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707 - 7901 Imaging Server Fax: (608) 260 - 2503 Telephone: (608) 266 - 1340 Fax: (608) 267 - 0394 http:// dwd.wisconsin .gov /wc e - mail: DWDDWC@dwd.wisconsin.gov American LegalNet, Inc. www.FormsWorkFlow.com