Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 3 - Hearing Rules › Chapter 66 - Miscellaneous › Subchapter E - Forms › Section I-6635 - Request for Social Security Benefits Information ; Form LDOL-WC-1004

Current through Register Vol. 50, No. 6, June 20, 2024
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
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.