Dol Form 25 - Wage Statement
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1Department of Labor, Workers’
DOL FORM 25
(Rev. 1/2018)
Workers’ Compensation
PO Box 488
State File No.
Montpelier, VT 05601-0488
Ins. Co. File No.
(802) 828-2286; TDD 800-650-4152
Date of Injury
Fed. ID No.
WAGE STATEMENT – For injuries occurring on or after July 1, 2008
Employee:
Employer:
Wage Rate:
$
per
Number of Days Hired to Work:
Number of Hours Hired to Work:
Week Ending
Number
Gross Wages
Extras (as in 6 or 7)
INSTRUCTIONS:
of
Please indicate what the
Read Carefully
Hours
extra is, for example,
Month
Day
Year
or Days
$1000.00 bonus
1. Enter GROSS wages of employee
Worked
for 26 weeks before date of accident
(NOT take-home pay).
1
2. Do not include the week of the
2
accident.
3
3. Leave blank those weeks in which
the employee had excused absences
4
for which he/she was paid for less
5
than ½ of a work week.
6
4. Leave blank those weeks in which
you had reduced operations or a plant
7
shutdown and for which the employee
8
was paid for less than ½ of a work
week.
9
5. Do not enter those weeks in which
10
an employee was on vacation for more
11
than ½ of a work week.
6. If room, board, lodging or other
12
“extras” (electricity, fuel, etc.) are
13
provided in addition to monetary
wages, break these down into a
14
weekly value, and include and
15
describe the income in the column
16
marked “EXTRAS.” This includes
tips if not included in gross wages.
17
7. Include any bonuses and
18
commissions paid to the employee in
19
addition to wages in the column
marked “EXTRAS.”
20
8. Enter the dates when your normal
21
work week ends (not the date a check
is issued to the employee) and the
22
number of hours or days worked.
23
24
25
26
When did the employee begin losing time?
Was the employee paid in full for the day of the accident?
Are employee’s wages subject to any child support withholding order?
Yes
No
If yes, in what amount?
$
per
Day of the week the check will be mailed to the claimant or deposited in the claimant’s account
This is a correct statement of the employee’s earnings as taken from the employer’s payroll records.
By:
Position Title:
Signature of Preparer
Print Name:
Date:
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