Free D-14 Form - Nevada


File Size: 5.7 kB
Pages: 1
File Format: PDF
State: Nevada
Category: Workers Compensation
Author: IIRS
Word Count: 132 Words, 1,657 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dirweb.state.nv.us/FORMS/d-14.pdf

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PERMANENT TOTAL DISABILITY REPORT OF EMPLOYMENT
Pension No. Please provide the earnings information for the periods shown below. Misrepresentation of the information requested is fraud and is a violation of Nevada law. Earnings are defined as wages, including overtime, commissions, salary, vacation, holiday and sick leave, termination pay, bonuses, tips declared for the purpose of receiving workers' compensation insurance after July 1, 1985, or other remuneration received from an employer for services rendered. MONTH YEAR AMOUNT OF EARNINGS $_____________________ $_____________________ $_____________________ $_____________________ $_____________________ $_____________________ $_____________________ $_____________________ $_____________________ $_____________________ $_____________________ $_____________________

1. ____________________________ _________ 2. ____________________________ _________ 3. ____________________________ _________ 4. ____________________________ _________ 5. ____________________________ _________ 6. ____________________________ _________ 7. ____________________________ _________ 8. ____________________________ _________ 9. ____________________________ _________ 10.____________________________ _________ 11.____________________________ _________ 12.____________________________ _________

I hereby declare that the earnings information provided above is correct to the best of my knowledge and that there has been no willful concealment, evasion, or enlargement of that information. Signature Name Address (P.O. Box, Apt., Street) City, State, Zip Code D-14 (rev. 7/99) Date

(Month, Day, Year)

Social Security No.