PRINT CLEAR
STATE OF CALIFORNIA
Department of Industrial Relations
Division of Workers' Compensation
WORKERS' COMPENSATION APPEALS BOARD
) ) ) Applicant ) ) ) ) ) ) Defendants )
Case No.
vs.
Petition for Commutation of Future Payments
NOTICE: Order may issue granting petition for commutation unless objection is filed within (10) days after date of service
1. Applicant requests
(A) that all future payments be commuted to a lump sum. (B) that sufficient final weekly payments be commuted to produce the sum of $________ (Strike out part not applicable)
2. The reason for requesting commutation is:
NOTE: Good cause must be shown under Labor Code Section 5100. No attorney fee will be allowed unless Requested. Dated:____________________________ Copies mailed to the following on Petitioner_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 19_ _ _
Attorney for Petitioner
___________________________________
ORDER COMMUTATION IS HEREBY ORDERED AS FOLLOWS:
Dated: ________________________________
Served by mail on persons shown on the official address record
_________________________________________
WORKERS' COMPENSATION JUDGE
By: __________________________________
DWC/WCAB FORM 49 (REV. 11-74)