Form Dwc40 - Statement Of Quarterly Earnings For Supplemental Income Benefits 1994 (Page 2 of 2) in pdf

Form Dwc40 - Statement Of Quarterly Earnings For Supplemental Income Benefits 1994 Page 2

STATEMENT OF QUARTERLY EARNINGS FOR SUPPLEMENTAL INCOME BENEFITS

EMPLOYEE NAME

SOCIAL SECURITY NUMBER

DATE OF ACCIDENT

INSTRUCTIONS:

(1)

Fill out Sections B and C on the front of this form.

Use the form that has the first two lines on the front of the form with your name, etc.

already completed. List any money you earned during the 13 weeks for the filing period

shown on the second line.

(2)

Attach copies of paycheck stubs, statements from your employer(s), or any other

documentation you may have of your earnings during the filing period.

(3)

If you have no earnings in a particular week, put down $0 for that week.

(4)

In the boxes below, list all employers you may have worked for during the filing period,

and the addresses, phone numbers and dates you were employed.

(5)

Sign and send the completed form to the carrier name and address noted in the lower

right-hand corner on the front of this form.

An LES Form DWC-40, Statement of Quarterly Earnings for Supplemental Income

Benefits, must be submitted at the end of every three months in order to receive these

benefits.

NAME OF EMPLOYER(S) DURING THIS FILING PERIOD

EMPLOYER

DATE(S)

NAME

ADDRESS

PHONE

EMPLOYED

LES Form DWC-40 (11/94)

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Form Dwc40 - Statement Of Quarterly Earnings For Supplemental Income Benefits 1994 Page 2