Free Download Form 10/10s in Adobe 9 Fill In Format - Vermont

DOL FORM 10/10s State File No. Ins. Co. File No. Date of Injury Fed. ID No.

(Rev. 5/05)

DEPARTMENT OF LABOR WORKERS' COMPENSATION DIVISION

CERTIFICATE OF DEPENDENCY AND EMPLOYEE EXEMPTION REPORT

EMPLOYEE: EMPLOYER:

SOCIAL SECURITY NO.:

TO THE EMPLOYEE: This form MUST be completed in every workers' compensation case in which an injured worker has lost time from work as the result of a work-related injury. The form must be completed even when the injured worker has no dependents. The information must be supplied and the form signed by the injured worker. This information is required by the Department of Labor to determine the employee's right to additional weekly compensation of $10.00 for each dependent child under the age of twenty-one (21) years.

PART A: FILING STATUS ­ Select One: [For purposes of determining Earned Income Credit (EIC)] Single Married or Civil Union

PART B: List below your dependent child(ren) that have not already been declared by your spouse or reciprocal beneficiary on his/her current workers' compensation claim, the child's date of birth, and their relationship to you. NAME OF DEPENDENT 1. 2. 3. 4. 5. DATE OF BIRTH RELATIONSHIP

I HEREBY CERTIFY that the above is a true, complete and accurate statement of my dependents.

Employee Signature

Address

Telephone Number

City/State