Form AWW - CON Average Weekly Wage Certification-Concurrent October 2016 Edition Filed: KENTUCKY DEPARTMENT OF WORKERS222 CLAIMS CLAIM NO. PLAINTIFF/EMPLOYEE VS WAGE CERTIFICATION DEFENDANT/EMPLOYER 1. Date of Injury/Exposure as reported on Claim Form 2. Method of Wage Payment (check one): Hourly Amount Daily Amount Weekly Salary Amount Monthly Salary Amount Yearly Salary Amount Output of Employee Amount 3. Date of Hire or Employment: 4. Name of concurrent employer: 5 . Did Employer provide any of the following (check appropriate ones): Board Rent Housing Lodging Fuel 6 . Did Employee (check appropriate ones): Work Overtime Receive Gratuities Paid Vacation/Holidays American LegalNet, Inc. www.FormsWorkFlow.com Plaintiff/Employee222s Name: Claim Number: Weeks Worked Month/Day/Year Total Regular and Overtime Hours Worked Regular Hourly Rate 1. X = 2. X = 3. X = 4. X = 5. X = 6. X = 7. X = 8. X = 9. X = 10. X = 11. X = 12. X = 13. X = Total: $ 367 by 13 weeks = $ 14. X = 15. X = 16. X = 17. X = 18. X = 19. X = 20. X = 21. X = 22. X = 23. X = 24. X = 25. X = 26. X = Total: $ 367 by 13 weeks = $ American LegalNet, Inc. www.FormsWorkFlow.com Weeks Worked Month/Day/Year Total Regular and Overtime Hours Worked Regular Hourly Rate 27 . X = 2 8 . X = 29 . X = 30 . X = 31 . X = 32 . X = 33 . X = 34 . X = 35 . X = 36 . X = 37 . X = 38 . X = 39 . X = Total: $ 367 by 13 weeks = $ 40 . X = 41 . X = 42 . X = 43 . X = 44 . X = 45 . X = 46 . X = 47 . X = 48 . X = 49 . X = 50 . X = 51 . X = 52 . X = Total: $ 367 by 13 weeks = $ American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATION I certify that the above wage information is a true and accurate accounting of my wages from the concurrent employer(s) identified above for the fifty-two (52) weeks prior to the date of injury or last exposure set forth in the Claim form. Plaintiff/Emplo y ee Signature Date CERTIFICATE OF SERVICE Unless this form has been submitted electronically, I certify that the origina l of this wage certification was mailed this day of , 20 to the C ommissioner and a copy of the same to Counsel of record and the assigned Administrative Law Judge. Attorney for the Plaintiff/Employee or Plaintiff/Employee American LegalNet, Inc. www.FormsWorkFlow.com