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New Jersey Department of LaborandWorkforce Development
DIVISION OF WORKERS COMPENSATION
WC-60 (R-6-07)

APPLICATION FOR COMMUTATION (WC-S-7)

C.P.NO.

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DATE FILED

NAME

TAX IDENTIFICATION NUMBER

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COUNTY OF RESIDENCE: ADDRESS

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NAME

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ADDRESS

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TELEPHONE (Area Code)

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NAME

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COUNTY OF RESIDENCE: ADDRESS

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MARITAL STATUS CITIZEN

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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

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No AGES SEX

REQULAR OCCUP ATION

PRESENT OCCUPAnON

LOCAnON OF PRESENT EMPLOYMENT

WEEllYWAGE

TOTAL FAMILY INCOME

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FIXED FAMILY NON-DEFERABLE EXPENSES $

Period of Temporary: Period of Permanency Paid: BalanceDue on Award:

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% of

or or

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weeks, or $ weeks, or $

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Amount Requested for Commutation:

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REASON FOR REQUEST FOR COMMUTATION: (Use additional sheets if necessary) PLEASE SUBMIT ANY COMMITMENTS TO SUBSTANTIATE YOUR REQUEST.

Signature of Applicant

(FOR DIVISION OF WORKERS' COMPENSATION USE ONLY)


Report ofInvestigation or Remarks (Attach Rider, if necessary)

(FOR DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT USE ONLY)

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APPROVED DISAPPROVED
JUDGE

_

Date: - - - - - - - -