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