What this form is for
Supplemental job displacement non-transferable voucher * Injuries occurring on or after 1/1/13 - - -
Official file
Published by the Division of Workers' Compensation. This page does not replace the form — it points at the state's PDF and, where the form is what a panel actually ruled on, quotes that ruling.
How to fill a DWC form →Source: dir.ca.gov/dwc/forms.html. Unofficial guide — the PDF on that site is the form.
What the Appeals Board did with this
Decisions of the Workers' Compensation Appeals Board that turned on this kind of filing. Each quotes the passage it turned on and links to the official PDF.
- ADJ9744423 · 2026-03-27 · Sacramento District OfficeSJDB voucherapplicant prevailed
Determinative passage · p.5Here, the WCJ issued a finding that defendant mailed the SJDV to applicant's address on the Official Address Record, which appears correct. However, the unrebutted testimony of applicant is that he was not living at that address at the time of service and that he did not receive the voucher. The WCJ found applicant's testimony credible. (See Garza, supra.) Thus, the evidentiary presumption is rebutted, and we will find that applicant did not receive the SJDV that defendant mailed in 2019.
Applicant's credible testimony that he did not receive the voucher rebutted the presumption of receipt, leading to a finding that applicant did not receive the voucher mailed to the official address record.
Official decision · page 5 → - ADJ13057590 · 2025-08-25 · Van Nuys District OfficeSJDB voucherdefendant prevailed
Determinative passage · p.1Applicant seeks reconsideration of the June 12, 2025 Findings of Fact and Orders (F&O) issued by the workers' compensation administrative law judge (WCJ). By the F&O, as relevant here, the WCJ found defendant produced proof of service for a supplemental job displacement voucher (SJDV), and under Evidence Code section 641, it is presumed that the defendant timely mailed the SJDV and the SJDV was received, and defendant acted reasonably and timely in replacing the voucher upon notice of actual non-receipt. The WCJ also found that though the voucher was not in fact received by applicant, applicant failed in their burden of proof to rebut the presumption and was not entitled to a penalty.
The Appeals Board found that defendant produced proof of service for the voucher, invoking the presumption under Evidence Code section 641 that the voucher was mailed and received. Applicant failed to produce believable contrary evidence to rebut this presumption. The WCJ and Appeals Board found no unreasonable delay warranting penalties or attorney fees.
Official decision · page 1 → - ADJ8759846 · 2025-06-05 · Marina del Rey District OfficeSJDB voucherdefendant prevailed
Determinative passage · p.10ORDER IT IS HEREBY ORDERED that the issues of temporary disability, permanent disability, applicability of Labor Code section 4658(d), apportionment, right to a supplemental job displacement voucher, attorney's fees, penalties, the EDD lien, and future medical for psyche are deferred, pending further development of the record. IT IS FURTHER ORDERED that an AME re-evaluation be scheduled with Dr. Albert Simpkins, Jr., and an updated report be requested from PQME, Dr. James Sherman. The issue of a medical-legal re-evaluation for applicant's injury to psyche is deferred.
Right to supplemental job displacement voucher deferred pending further development of the record.
Official decision · page 10 → - ADJ11110973 · 2025-05-23 · Los Angeles District OfficeSJDB voucherdefendant prevailed
Determinative passage · p.1Applicant seeks reconsideration of the August 15, 2023 Findings and Order, wherein the workers' compensation administrative law judge (WCJ) found that applicant is not entitled to an additional payment from the Return-to-Work Supplement Program (RTWSP) because applicant received an earlier RTWSP in connection with a prior injury after the date of the instant injury from which applicant is claiming RTWSP benefits. Rule 17302(b) prohibits a second or subsequent RTWSP payment "except where the individual receives a [Supplemental Job Displacement Benefit (SJDB)] Voucher for an injury which occurs subsequent to receipt of every previous Return to Work Supplement." (Cal. Code Regs., tit. 8, § 17302(b).)
The Board found that Rule 17302(b) prohibits a second RTWSP payment unless the individual receives a subsequent SJDB Voucher for a later injury, and the applicant did not meet this requirement. The Board also held that the applicant's remedy to challenge the regulation's validity lies in Superior Court, not the Appeals Board.
Official decision · page 1 →