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WC(DO)-103 (r 4/11/06) State of New Jersey Department of Labor and Workforce Development Division of Workers' Compensation
SOCIAL SECURITY NUMBER

ORDER FOR DISTRIBUTION (For Child Support) Page 1 of 2

WC CASE NO. (S) _________________ __________________________________ District Office: _____________________

FEIN ATTORNEY FOR PETITIONER INSURANCE CARRIER PROBATION CASE NO. CSNAME ADDRESS

PETITIONER

NAME

AGE

ADDRESS (Including County)

APPEARING

VS
RESPONDENT NAME ADDRESS (Including County) NAME (Indicate if Not Covered or if Self-Insured)

ATTORNEY FOR RESPONDENT

NAME ADDRESS (Including County)

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 are $_____________ 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.

WC (DO)-103.1 (r 4/11/06) State of New Jersey Department of Labor and Workforce Development Division of Workers Compensation

ORDER FOR DISTRIBUTION (For Child Support) Page 2 of 2

WC CASE NO. (S) __________________ __________________________________ District Office: _____________________

IT IS ON THIS ___________ DAY OF ____________,______, HEREBY ORDERED THAT

1. The petitioner shall pay $___________ for Child Support arrearage(s), through the ______________ Probation Division. The employer or employer's insurance carrier shall deduct said payment from the petitioner's net proceeds. 2. The employer or employer's insurance carrier shall contact the _______________ 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. A copy of this order shall be served upon the ______________ Probation Division by the respondent's attorney within 10 days from the execution of this order.

_________________________
Petitioner's Attorney

______________________________
Judge of Compensation

__________________________
Petitioner ____________________________ Respondent's Attorney

______________________________
Name (Print or Type)