How to Fill Out the DWC-AD Form 10133: Supplemental Job Displacement Voucher

The DWC-AD 10133.32 form is the Supplemental Job Displacement Non-Transferable Voucher issued in a California workers’ compensation claim, worth up to $6,000 toward retraining after a permanent partial disability. Your claims administrator fills in the top of the form with your identifying information and the expiration date, then sends the packet to you. You fill in your training provider or vocational counselor details on page 2, sign it, and return it. From there, the claims administrator pays the school, counselor, or vendor directly, or reimburses you for what you have already paid.1California Department of Industrial Relations. DWC-AD 10133.32 – Supplemental Job Displacement Non-Transferable Voucher Form

What Comes in the Voucher Packet

Form 10133.32 is not a single page. The packet the claims administrator sends you includes the voucher itself, a miscellaneous expense request page, a computer equipment request page, a page for training provider details, and a proof-of-service page at the back. Blank copies of every page are posted on the Department of Industrial Relations website if yours arrives incomplete or you want to review the layout before you sign anything.2California Department of Industrial Relations. DWC Forms

Keep the full packet together. The proof-of-service page in particular carries the date the voucher was served on you, and that date controls two separate deadlines later on.

What the Claims Administrator Fills In

Before the voucher reaches you, the claims administrator completes the top section with your name, the claim number, the claims administrator’s contact information, the date of injury, and the voucher expiration date. You do not need to supply your Social Security number or your WCAB case number on the main voucher pages. The ADJ number appears only on the proof-of-service page at the back.1California Department of Industrial Relations. DWC-AD 10133.32 – Supplemental Job Displacement Non-Transferable Voucher Form

Check the expiration date as soon as the packet arrives. Everything you plan to do with the $6,000 has to happen before that date.

What You Fill In

Your section is on the second page and lists your training choices:

  • Training provider or school name, address, phone number, and the cost of the program.
  • If you choose to use a vocational return-to-work counselor (VRTWC), the counselor’s name, address, and the amount allocated for counseling, up to $600.
  • Your signature and the date, which authorizes the claims administrator to make payments on your behalf.

Sign and return the page with your training details so the claims administrator can pay the school or counselor directly, or reimburse you for costs you have already paid out of pocket.

The $500 Miscellaneous Expense Request

Page 3 of the packet is the fastest money in the voucher. You can request up to $500 as a miscellaneous expense advance, and no itemized receipts or documentation are required for this amount. Mail or email the completed page 3 to the claims administrator and the payment comes to you.1California Department of Industrial Relations. DWC-AD 10133.32 – Supplemental Job Displacement Non-Transferable Voucher Form If you submit it by email, keep the sent message and any delivery confirmation. If you mail it, use certified mail with a return receipt.

What the $6,000 Covers

All of the following categories draw from the same $6,000 pool:3Department of Industrial Relations. Answers to Frequently Asked Questions About Supplemental Job Displacement Benefits

  • Tuition and training fees at a California public school or a provider on the state’s approved list, searchable through CalJOBS.4Division of Workers’ Compensation. Supplemental Job Displacement Benefits
  • Licensing and certification fees, including exam, testing, and application costs.
  • Tools required by a training course.
  • Computer equipment up to $1,000, covering a computer, monitor, printer, tablet, software, networking devices, or peripherals. No games or entertainment media. The employer may also offer to supply the equipment directly.1California Department of Industrial Relations. DWC-AD 10133.32 – Supplemental Job Displacement Non-Transferable Voucher Form
  • Miscellaneous expenses up to $500, through page 3 of the packet.
  • Vocational return-to-work counseling up to $600, which cannot exceed 10% of the voucher.

The voucher does not cover transportation, internet service, clothing, or other incidental costs beyond that $500 lump sum.1California Department of Industrial Relations. DWC-AD 10133.32 – Supplemental Job Displacement Non-Transferable Voucher Form The amount is a flat $6,000 regardless of disability percentage; a 5% permanent partial disability and an 80% permanent partial disability receive the same voucher.5California Legislative Information. California Code LAB 4658.7 – Supplemental Job Displacement Benefit

Keep a running tally. Once you reach $6,000 in combined payments, the voucher is exhausted whether your program is finished or not.

Picking an Approved Training Provider

For injuries on or after January 1, 2013, the provider must be a California public school or a provider listed through the CalJOBS website. The Division of Workers’ Compensation posts step-by-step search instructions for filtering CalJOBS for approved SJDB training providers.4Division of Workers’ Compensation. Supplemental Job Displacement Benefits A vocational counselor is optional. If your medical restrictions narrow your options or you are not sure what field is realistic, a VRTWC can match your restrictions to programs that fit. The DWC maintains a list of counselors.

When Payment Should Arrive

After you submit the completed voucher with your training details, receipts, or a reimbursement request, the claims administrator has 45 calendar days to issue payment, whether that payment goes to you, the training provider, or the counselor.6Department of Industrial Relations. 8 CCR 10133.56 – Requirement to Issue Supplemental Job Displacement Voucher Certified mail with a return receipt gives you a clean record of when the 45-day clock started. Keep your own copy of every page you send and every receipt you submit.

When the Voucher Expires

The voucher expires on the later of two dates: two years after it was issued to you, or five years after the date of injury.7Department of Industrial Relations. 8 CCR 10133.31 – Supplemental Job Displacement Nontransferable Voucher for Injuries Occurring on or After January 1, 2013 Expenses not incurred and submitted with documentation before that date are lost, even if you still have unused balance. The expiration date is printed on the front page of the voucher. Check it before enrolling in any long program, and work backward from it when scheduling training, testing, and reimbursement submissions.

The Separate $5,000 Return-to-Work Supplement

If you received the voucher, you are also likely eligible for a separate one-time $5,000 payment from California’s Return-to-Work Supplement Program. It is not part of the voucher and does not come from your employer’s insurance. It is paid by the state directly to the worker.8Department of Industrial Relations. Return-to-Work Supplement Program

Eligibility requires an injury date on or after January 1, 2013, and that you have received an SJDB voucher. The application must reach the DWC within one year from the date the voucher was served on you. You will need the entire SJDB voucher packet including the proof-of-service page, your ADJ number and workers’ compensation claim number, and the proof-of-service date from the voucher.

Applications are filed online through the DWC website. Every DWC district office has a kiosk with a computer, scanner, and printer if you do not have internet access.8Department of Industrial Relations. Return-to-Work Supplement Program Once a completed application is filed, the DWC makes an eligibility decision within 60 days and issues payment within 25 days after that. Many workers never claim this money because they do not know it exists; the one-year clock runs from the date on the proof-of-service page.

If the Claims Administrator Denies or Ignores the Voucher

If the claims administrator denies the voucher, disputes the amount, fails to pay a training provider on time, or you have another SJDB-related objection, file Form DWC-AD 10133.55, the Request for Dispute Resolution Before the Administrative Director.1California Department of Industrial Relations. DWC-AD 10133.32 – Supplemental Job Displacement Non-Transferable Voucher Form

Before filing, try to resolve the problem directly with the claims administrator and keep records of the attempt. The form requires a summary of those informal efforts. Mail the completed request with supporting documents to the Administrative Director, Division of Workers’ Compensation, P.O. Box 420603, San Francisco, CA 94142-0603, and serve copies on all other parties.

After filing, the opposing party has 20 calendar days to respond. The Administrative Director issues a written decision within 30 calendar days of that response. If the Director requests additional information, the 30-day clock restarts from the date that information is received. If no decision issues within 60 calendar days of the response deadline (or 60 days after receipt of additional information, whichever is later), the request is treated as denied.