Insurers Quarterly Workers Compensation Surcharge Return {ACG-TTF-20}

State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-377i (r.3/19/13) ADDENDUM TO ORDER FOR TOTAL DISABILITY CASE NO'S.: VICINAGE: Case Name: Petitioner's Social Security Number: Petitioner is in receipt of a government ordinary disability retirement pension. The date of retirement was . The initial retirement benefit was $ per month. The pension portion of the retirement benefit was $ per month. The annuity portion of the retirement benefit was $ per month. The respondent and/or the Second Injury Fund is/are entitled to an offset for this benefit. Based upon the last compensable injury and the reasons for the ordinary disability retirement, the offset shall be % of the pension portion of the retirement benefit, or $ per week resulting in a weekly rate of $ . Other: DATE JUDGE OF COMPENSATION WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND ACKNOWLEDGE RECEIPT OF COPY: PETITIONER'S ATTORNEY RESPONDENT'S ATTORNEY PETITIONER (where applicable) DEPUTY ATTORNEY GENERAL American LegalNet, Inc. www.FormsWorkFlow.com