Fill and Sign the Nj Workers Compensation Form 497319696

              District Office:                                                                                                                                                             are $             does/ does not support a current does/ does not owe more than twelve weeks arrears on obligor's support a ''lump sum" accumulated payments continuing periodic / / State of New JerseyDepartment of Labor Division of Workers' Compensation ORDER FOR DISTRIBUTION (For Child Support) Page 1 of 2 CASE NO.(S) SOCIAL SECURITY NUMBER FEDERAL EMPLOYER'S IDENTIFICATION NUMBERP E T I T I O N E R NAME AGE NAME ADDRESS (including County) ADDRESS A T T P O R N E Y F O R P E T I T I O N E R APPEARING VS R E S P O N D E N T NAME NAME (Indicate if Not Covered or if Self-insured) ADDRESS (including County) A T T P O R N E Y F O R R E S P O N D E N T NAME C A R RI E R ADDRESS (including County)IN S U R A N C E Probation Case No. CS- APPEARING 1. The Division of Workers' Compensation has matched data received from the New Jersey Administrative Office of the Courts on child support judgment debtors against the information the Division maintains for individuals who have filed workers' compensation claims, and the match has identified the petitioner as a child support judgment debtor; 2. Total support arrears owed by the petitioner on all cases enforceable through the state Probation Division as of , as indicated in the records of Probation . Division; 3. The net proceeds of the within award are more than $2,000.00, after payment of attorney fees, witness fees, costs, fees payable to health care providers, reimbursement to the employer, employer's insurance carrier, Second Injury Fund of the State of New Jersey, State Division of Temporary Disability Insurance and an approved Private Plan covered under the Temporary Disability Benefits Law or other reimbursement to an employer or employer's workers' compensation carrier as provided in R.S.34:15-40; 4. The petitioner has one or more support orders and spouse or child not covered by a current child support order; 5. The petitioner orders, in total, 6. The net award represents payments, WC-103-1 (R-3-01)      District Off ice,       IT IS ON THIS       DAY OF       The petitioner shall pay $       for Child Support arrearage(s), through the       The employer or employer's insurance carrier shall contact the       A copy of this order shall be served upon the                                     State of New JerseyDepartment of Labor Division of Workers' Compensation ORDER FOR DISTRIBUTION (For Child Support) Page 2 of 2 CASE NO.(S) - - , HEREBY ORDERED THAT 1 . Probation Division for obligations due from petitioner's award through the date of the execution of this order. The employer or employer's insurance carrier shall deduct said payment from the petitioner's net proceeds. 2. Probation Division prior to the distribution of proceeds to the petitioner in order to arrange for the satisfaction of the child support judgment. 3. This order adjudicates the disbursement of net proceeds of the within award as it pertains to satisfaction of the above referenced child support obligation. All other provisions previously entered in this or related matters shall remain in full force and effect until further order of the court. 4. Periodic indemnity benefits due and owing from the date of the execution of the within order are subject to the appropriate garnishment rate until such time as the child support obligations have been satisfied or indemnity, benefits exhausted. The employer or employer's carrier shall contact the applicable Probation Department to verify rates and amounts and shall make payments as appropriate. 5. Probation Division by the respondent's attorney within 10 days from the execution. of this order. Petitioner's Attorney Judge of Compensation Petitioner Name (Print or Type) Respondent's Attorney WC-103-1 (R-3-01)