Form C-41 Wage Statement -Tennessee Department Of Labor And Workforce Development
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1FORM C-41
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
220 French Landing Dr.
Nashville, Tennessee 37243-1002
WAGE STATEMENT
It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers'
compensation transaction for the purpose of committing fraud. Penalties include imprisonment, fines and
denial of insurance benefits.
Employee:__________________________ SSN:
State File # _______________________
_____________________
______________________________
Insurer Claim #:
Date of Injury
In order to determine the correct rate of compensation to be paid to the above injured party, please fill
in the schedule below and return it promptly. This information is required by law and no agreement
for payment of compensation can be made until it has been received. Please complete 52 weeks prior
to date of accident.
Please describe allowances of any character made in lieu of wages that must be deemed a part of
employee's earnings: _______________________________________________________________
If the average weekly wage is not based on fifty-two weeks of earnings proceeding the date of injury,
please show your computation below: _________________________________________________
WEEK
NO.
WEEK ENDING
GROSS WAGES
WEEK
NO.
WEEK ENDING
GROSS WAGES
DAYS
DAYS
1
27
2
28
3
29
4
30
5
31
6
32
7
33
8
34
9
35
10
36
11
37
12
38
13
39
14
40
15
41
16
42
17
43
18
44
19
45
20
46
21
47
22
48
23
49
24
50
25
51
26
52
TOTAL PAID
Rate per Day _______________ Rate per Hour_____________ Average per Week _________________
I hereby certify that the above is a true and correct account, as taken from our time books or payroll records, of the wages
paid to the above-named injured employee for the periods indicated.
Date ______________ 20____
Employer
______________________________________________
Name of Preparer & Title _________________________________________________________________
Phone, Fax, Email
_____________________________________________________________________
LB-0384 (
. 01/08)
RDA 10183
REV
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