1. REVISION DATE: // MM DD YYYY MEMORANDUM OF PAYMENT 2. WCB FILE NUMBER (if known): EMPLOYEE 3. EMPLOYEE LAST NAME: 4. FIRST NAME: 5. MI.: 6. SOCIAL SECURITY NUMBER (last 4 digits) : XXX-XX- 7. ST REET/P.O. BOX MAILING ADDRESS: 8. CITY: 9. STATE: 10. ZIP: 11. HOME PHONE NUMBER: ( ) 12. DATE OF INJURY: // MM DD YYYY 13. SPECIFIC INJURY OR ILLNESS: 14. BODY PARTS (S) AFFECTED: EMPLOYER 15. INSURER FILE NUMBER: 16. EMP LOYER NAME: 17. EMPLOYER MAILING ADDRESS AND PHONE NUMBER: 18. INSURER NAME: 19.INSURER MAILING ADDRESS AND PHONE NUMBER : NOTICE TO EMPLOYEE 20. YOUR EMPLOYER/INSURER IS REQUIRED TO FILE THIS WORKERS222 COMPENSATION FORM UPON PAYMENT OF A LOST TIME WORK-RELATED INJURY. PAYMENT IS MADE FOR THE FOLLOWING REASON: A. YOUR CLAIM IS ACCEPTED. B. THIS IS A VOLUNTARY PAYMENT WITHOUT PREJUDICE. C. THIS IS A MANDATORY PAYMENT PURSUANT TO RULE 1.1. AMOUNT PAID $ . PERIOD COVERED BY MANDATORY PAYMENT: FROM (DATE CLAIM MADE) // THROUGH (DATE NOTICE OF CONTROVERSY FILED AND BENEFITS PAID) // MM DD YYYY MM DD YYYY 21. TYPE OF PAYMENT: A. WEEKLY COMPENSATION B. SPECIFIC LOSS: WEEKS C. OTHER (EXPLAIN): 22. FIRST DAY OF COMPENSABILITY AFTER WAITING PERIOD WAS MET: // MM DD YYYY 23. DATE OF INCAPACITY: // MM DD YYYY DATE EMPLOYER NOTIFIED OF INCAPACITY: // MM DD YYYY 24. DATE CHECK MAILED: // MM DD YYYY 25. AVERAGE WEEKLY WAGE: $ 26. CURRENT WEEKLY COMPENSATION RATE: TOTAL PARTIAL $ (IF VARYING RATES ARE BEING PAID, ENTER THE WORD 223VARYING224) 27. IS THIS AN APPORTIONMENT CLAIM? YES NO IF YES, ANSWER THE FOLLOWING: OTHER DATE(S) OF INJURY INVOLVED: OTHER INSURER(S) INVOLVED: EXPLAIN THE TERMS OF THE APPORTIONMENT: 28 . COMMENTS: ASSISTANCE IS AVAILABLE AT THE MAINE WORKERS222 COMPENSATION BOARD222S REGIONAL OFFICES AUGUSTA 442 CIVIC CTR. DRIVE, STE 225 156 STATE HOUSE STATION AUGUSTA, ME 04333-0156 (207) 287-2308 1 - 800 - 400 - 6854 BANGOR 106 HOGAN RD BANGOR, ME 04401-5638 (207) 941-4550 1 - 800 - 400 - 6856 CARIBOU ONE VAUGHN PL 43 HATCH DR, STE 110 CARIBOU, ME 04736 (207) 498-6428 1 - 800 - 400 - 6855 LEWISTON 36 MOLLISON WAY LEWISTON, ME 04240-7777 (207) 753-7700 1 - 800 - 400 - 6857 PORTLAND 1037 FOREST AVE, STE 11 PORTLAND, ME 04103 (207) 822-0840 1 - 800 - 400 - 6858 29 . PREPARER NAME (TYPE OR PRINT): E-MAIL ADDRESS: 3 0 . TELEPHONE NUMBER: ( ) TOLL-FREE NUMBER: ( ) 3 1 . DATE MAILED : // MM DD YYYY The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon request. For assistance with this form, contact the ADA Coordinator at the Maine Workers222 Compensation Board. Telephone: 1-888-801-9087 or TTY Maine Relay 711. WCB-3 (eff. 9/1/18, rev. 1/28/19) American LegalNet, Inc. www.FormsWorkFlow.com