Free State of New Jersey - New Jersey

State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-377i (r.02-08-07)

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