<p> Overpayment Checklist</p><p>IW Name: Claim #(‘s): </p><p>Check which applies: issued an adjustment order sent notification of IC declared overpayment letter</p><p>Payment Plan Reviewed: (include all claims for IW and vacates) Cancelled Warrants Estimated Payments</p><p>Cause of Overpayment (check all that apply): AWW Adjustment Incarcerated Clerical Error LM to TT Duplicate Payments MMI Fraud Rehab Plan Ended FWW Adjustment Return to Work IC Reversal to an order TT to LM ODJFS Wrong Wage Loss Wages Other: (please explain) </p><p>Overpayment Worksheet Completed: Data Warehouse Warrant History Report Run Adjustment needed by V3 CST (Consult with V3 Coordinator) Overpayment Worksheet Link</p><p>Adjustment Order Completed: Absorption rate set at 0% until order is final Overpayment moved to different type if there is a pre-existing overpayment</p><p>Follow-up Diary Set: Absorption Percent Correct (reminder: 0% absorption for 1st 12 weeks of TT) End of Appeal Period Diary to Modify Absorption Percent Diary to adjust comp at end of appeal period if necessary Absorption Rates Link</p><p>V3 Note Completed (items to include in note): Cause of Overpayment Canceled warrants resolved Compensation Type Estimated or released payments explained Absorption Percent Outcome of Overpayment Worksheet</p><p>Notification to Employer Rate Adjustment Unit Necessary? Yes No</p><p>Imaged into Claim: Overpayment checklist Overpayment worksheet Documentation to Support Overpayment</p><p>Completed By: Date: </p>