La. Admin. Code tit. 40 § I-6635

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-6635 - Request for Social Security Benefits Information ; Form LDOL-WC-1004

REQUEST FOR SOCIAL SECURITY BENEFITS INFORMATION

(L.R.S. 23:1225)

DATE_______________________________________

NAME______________________________________ SSN____________________________________________

Please provide information concerning the referenced worker.

______________________________________________

Workers' Compensation Judge

Type of Social Security Benefit: _____ Disability _____ Retirement _____ Other _____ None

Current Social Security Benefit Paid to Employee ..................................................................................................................... $________________

Number of Auxillaries/Dependants on Record ......................................................................................................................... #________________

Age of Youngest Auxillary/Dependant ................................................................................................................................. ________________

PART I - CALCULATION OF INITIAL OFFSET

Date of Entitlement __________________

1. Original 80 Percent Average Current Earnings (ACE) on Record ........................................................................................... $________________

2. Total Family Benefit (TFB) ..................................................................................................................................................... $________________

3. Higher of Amounts Shown Above ............................................................................................................................................ $________________

4. Monthly Workers' Compensation (WC) Rate

(Subject to reduction due to allowable expenses)......................................................................................................................... $________________

5. Social Security Benefits Payable After Offset in Month of Entitlement

(#3 minus #4, if a negative amount show 0)............................................................................................................................... $________________

6. Original Federal Offset Amount (#2 minus #5).......................................................................................................................... $________________

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

PART II - CHANGE IN FEDERAL OFFSET AMOUNT DUE TO TRIENNIAL REDETERMINATION OF THE ACE ( 42 USC 424(F) (1) and 20 CFR 404.408(1) )

Effective January ___________________

1. Redetermined 80 Percent ACE ................................................................................................................................................. $________________

2. Original 80 Percent ACE ......................................................................................................................................................... $________________

3. Difference Between Original and Redetermined ACE (#2 minus #1)......................................................................................... $________________

4. Cost of Living Allowance (COLA) Increases for Same Period of Time (Date of Entitlement Through

Date of Redetermination .......................................................................................................................................................... $________________

5. Decrease in Offset (#3 minus #4; if negative, show 0)............................................................................................................... $________________

6. Federal Offset Amount (#6 in Part I minus #5)......................................................................................................................... $________________

The next Triennial Redetermination of the ACE should be completed in ..................................................................................................... ___/___/___

PREPARED BY: _____________________________________________

Social Security Field Office

La. Admin. Code tit. 40, § I-6635

Promulgated by the Department of Labor, Office of Workers' Compensation Administration, LR 25:290 (February 1999).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1310.1.

**NOTE from the Office of the State Register: The backside of this form (LDOL-WC-1004) was not included on the disk. This form will need to be scanned or obtained from the agency.