Free Microsoft Word - Form25 5 08 changes - Vermont

DOL FORM 25 STATE OF VERMONT Department of Labor Workers' Compensation 5 Green Mountain Drive, PO Box 488 Montpelier, VT 05601-0488 WAGE STATEMENT ­ For Injuries on or after July 1, 2008 Employee: Employer: Wage Rate: $ per Number of Days Hired to Work: Number of Hours or Days Worked Gross Wages Social Security No.: State File No. Ins. Co. File No. Date of Injury Fed. ID No.

(Rev 6/08)

Number of Hours Hired to Work:

Week Ending Month Day Year

Extras (as in 6 or 7) Please indicate what the extra is, for example, $1000.00 bonus

INSTRUCTIONS: Read Carefully 1. Enter GROSS wages of employee for 26 weeks before date of accident (NOT take home pay). 2. Do not include the week of the accident. 3. Leave blank those weeks where the employee had excused absences for which he/she was not paid for more than ½ of a work week. 4. Leave blank those weeks where you had reduced operations or a shutdown of the plant for which he/she was not paid for more than ½ of a work week. 5. Do not enter those weeks where an employee was on vacation for more than ½ of a work week. 6. If room, board, lodging or other "extras" (electricity, fuel, etc.) are provided in addition to monetary wages, break it down into a weekly value, include and describe this income in column marked "EXTRAS." This includes tips if not included in gross wages. 7. Include any bonuses and commissions paid to the employee in addition to wages in the column marked "EXTRAS." 8. Enter the dates when your normal work week ends (not the date a check is given to the employee) and the number of hours or days worked.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
When did the employee begin losing time? Are employee's wages subject to any child support withholding order? If yes, in what amount? $ Yes per No

Was the employee paid in full for the day of the accident?

This is a correct statement of the employee's earnings as taken from the employer's payroll records. By: Signature of Preparer Print Name: Date: Position Title: