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OPINION/ORDER Defendants(s)/Carrier(s) A. B. C. D. Type of Claim Type of Award ) Injury Date(s) Established Average Weekly Wage Discontinued Fringes Date Discontinued IRS Filing Status: Dependents - Date of Marriage/Birth Name Date Name Date Name IT IS FOUND Defendant/Carrier At the weekly rate of From Through IT IS FURTHER FOUND IT IS FURTHER ORDERED IT IS FURTHER ORDERED IT IS FURTHER ORDERED Date American LegalNet, Inc. www.FormsWorkFlow.com