State of New Jersey
|State of New Jersey |ADDENDUM TO |CASE NO’S.: |
|Department of Labor and Workforce Development |ORDER FOR | |
|DIVISION OF WORKERS’ COMPENSATION |TOTAL DISABILITY | |
| | | |
|WC-377i (r.3/19/13) | | |
| | |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: |
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| |DATE |
|JUDGE OF COMPENSATION | |
|WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND ACKNOWLEDGE RECEIPT | | |
|OF COPY: | | |
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|PETITIONER’S ATTORNEY | |RESPONDENT’S ATTORNEY |
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|PETITIONER (where applicable) | | |
| | |DEPUTY ATTORNEY GENERAL |
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