WORKERS' COMPENSATION COMMISSION 10 EAST BALTIMORE STREET BALTIMORE, MARYLAND 21202-1641
STIPULATION FOR ADVANCEMENT
Instructions: This form is to be used only to document an advance agreed upon by all parties.
WCC Claim Number
Social Security Number:
STIPULATION FOR ADVANCE
It is hereby stipulated between the parties that the Employer/Insurer will advance the Claimant the sum of $ compensation benefits. to be credited against any future
Attorney for Claimant (Signature)
The above agreement is approved by the Workers' Compensation Commission this day of ,2 .
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WCC Form C50R (Rev. 9/2006)