La. Admin. Code tit. 40 § I-6637
Attached hereto and designated as "Attachment Number 5."
STATE OF LOUISIANA
DEPARTMENT OF LABOR
OFFICE OF WORKERS' COMPENSATION
__________________________________________________________ * SS#:
VERSUS * DOCKET NO:________________________
___________________ * DISTRICT:
MOTION FOR RECOGNITION OF RIGHT TO SOCIAL SECURITY OFFSET
NOW INTO COURT as undersigned comes ______________________________________________, employer/insurer in the referenced case, and requests the Workers' Compensation Judge to enter an order recognizing its right to take the reverse offset, since the claimant in this matter is receiving permanent total disability benefits under the Louisiana Workers' Compensation Act in addition to benefits under 42 U.S.C. Chapter 7, Subchapter II, entitled Federal Old Age, Survivors, and Disability Insurance Benefits.
SIGNED this the day of , 20__.
__________________________
(PRINT NAME)
Agent for _________________
La. Admin. Code tit. 40, § I-6637