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Supplemental Wage Schedule Form. This is a New Hampshire form and can be use in General Workers Comp.
Tags: Supplemental Wage Schedule, NH 76 WCA1, New Hampshire Workers Comp, General
COURT
COUNTY .OF. . . . . . . . . . . . . . . .THE .STATE. OF .NEW. HAMPSHIRE
......... ..
.... ..... ... .... ......
:
Index
DEPARTMENT OF LABORNo.
CONCORD, N.H. 03301
:
:
Plaintiff(s)
Calendar No.
JUDICIAL SUBPOENA
SUPPLEMENTAL WAGE : SCHEDULE
-against:
:
TO BE COMPLETED ONLY WHEN INDEMNITY RATE IS BASED ON AFTER-TAX EARNINGS AS DEFINED BY RSA 281-A:2, 1-a.
Defendant(s)
:
......................................................
TOTAL NUMBER OF DEPENDENTS (INCLUDES EMPLOYEE)
THE PEOPLE OF THE STATE OF NEW YORK
FILING STATUS (MARRIED OR SINGLE)
TO
List names and ages of all dependents
6
1
GREETINGS:
2
7
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
8
located at
County of
in room
, on the
day of
, 20 9 , at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
3
4
5
10
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
Averageresult ofWage failure to comply.
Weekly your
Line 1
Amount of Federal Witness, Honorable Deducted
Withholding Tax to be
using Figure from Line 1
Court in
County,
day of
, one of the Justices of the
Line 2
, 20
Line 3
FICA rate factor
Multiply amount from Line 1 by FICA rate factor
(Attorney must sign above and type name below)
Line 4
Line 5
Total Deductions (Add Lines 2 and 4)
AFTER-TAX EARNINGS INDEMNITY RATE
(Subtract amount in Line 5 from amount in Line 1)
Attorney(s) for
Line 6
Office and P.O. Address
Signature – Employee
Date
NH 76WCA1
Signature – Adjuster
Telephone No.:
Facsimile No.:
Date E-Mail Address:
White – Labor Dept. (Mail to Carrier) Mobile Tel. No.:
Canary – Insurance Carrier (Mail to Carrier)
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