Application For Commutation {WC-60}

New Jersey Department of LaborandWorkforce Development DIVISION OF WORKERS COMPENSATION WC-60 (R-6-07) APPLICATION FOR COMMUTATION (WC-S-7) C.P.NO. .. DATE FILED NAME TAX IDENTIFICATION NUMBER 1-< ...... 1-< W 0 ~ ...... ~ COUNTY OF RESIDENCE: ADDRESS 0:: 00:: NAME ~~ ~~ O~ ADDRESS -< TELEPHONE (Area Code) ~g: TELEPHONE (Area Code) vs NAME 1-< NAME 0 SELF-INSURED o NOT-COVERED ffi @ [:2 rr. 0 COUNTY OF RESIDENCE: ADDRESS II ~u MARITAL STATUS CITIZEN w CLAIM FILE No. ADDRESS TIPE OF HEARING PLACE OF HEARlNG HEARING OFFICIAL o Formal o .Informal SEX AGE DATE OF JUDGMENT DATE OF ACCIDENT Dyes DEPENDENTS NAMES o No AGES SEX REQULAR OCCUP ATION PRESENT OCCUPAnON LOCAnON OF PRESENT EMPLOYMENT WEEllYWAGE TOTAL FAMILY INCOME s s FIXED FAMILY NON-DEFERABLE EXPENSES $ Period of Temporary: Period of Permanency Paid: BalanceDue on Award: to % of or or ~_ _ weeks, or $ weeks, or $ _ _ Amount Requested for Commutation: _ REASON FOR REQUEST FOR COMMUTATION: (Use additional sheets if necessary) PLEASE SUBMIT ANY COMMITMENTS TO SUBSTANTIATE YOUR REQUEST. Signature of Applicant American LegalNet, Inc. www.FormsWorkflow.com (FOR DIVISION OF WORKERS' COMPENSATION USE ONLY) Report ofInvestigation or Remarks (Attach Rider, if necessary) (FOR DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT USE ONLY) D D APPROVED DISAPPROVED JUDGE _ Date: - - - - - - - - American LegalNet, Inc. www.FormsWorkflow.com