Minnesota Department of Labor and Industry Financial Services 443 Lafayette Road North St. Paul, MN 55155-4310 (651) 284-5021 or (800) 342-5354 NO0015 DO NOT USE THIS SPACE Notice of Penalty Payment Attach this to the ARSA payment and mail to the above address WID DATE OF INJURY EMPLOYEE EMPLOYER INSURER/ADJUSTING COMPANY INSURER/ADJUSTING COMPANY CLAIM NUMBER PENALTY NUMBER SERVED AND FILED TO BE FILLED OUT BY PAYOR (Check one or both) This is to certify that the $ for deposit in the Assigned Risk Safety Account. penalty assessment was paid to the Commissioner This is to certify that the above-captioned employee was paid the $ assessment in accordance with Minnesota Statute § 176.225 on penalty (date) Payor's Signature Date Printed Name and Title Phone Number Online payment is now available at: www.dli.mn.gov/paycenter For online payment assistance call: Department of Labor and Industry, Financial Services at 651-284-5021 Department of Labor and Industry Federal Tax ID # 41-6007162 MN NO0015 (10/14) American LegalNet, Inc. www.FormsWorkFlow.com