Workers' Compensation Division Preferred Worker Program Wage Subsidy Reimbursement Request Employer legal name: Federal tax ID number: Worker/employer information Worker name: WCD number: (from front of preferred worker card) Person completing form: Phone: Fax: Complete mailing address (address to which check is to be mailed): Instructions (See reverse side for helpful information.) Please refer to the Approved Wage Subsidy Agreement for pertinent wage information. (1) Attach one legible copy of worker's pay records or copy of a pay stub that includes worker's name, employer's name, pay period, hours worked, wage rate, and gross wages paid for the period entered on line (A), below. (2) (3) (4) (5) Employer must sign and date each reimbursement request. All requests must be made within one year of end date of the agreement. Keep one copy of this completed reimbursement request for your records. Fax a copy of this reimbursement request and all payroll records for this pay period to 503-947-7581. If you prefer, you can mail the information to: Preferred Worker Program, Workers' Compensation Division, 350 Winter St. NE, P.O. Box 14480, Salem, OR 97309-0405. The wages for reimbursement must be paid during the agreement start date of and end date of . (6) Reimbursement information (A) (B) (C) Wages paid from Gross wages $ Is this your final request? Yes No through Complete this box when agreement is interrupted. A wage subsidy may be interrupted ONCE for reasonable cause on a whole-workday basis. A layoff must be a minimum of 10 consecutive days. Reason for interruption: I certify all amounts shown have been paid to the worker for the period indicated, workers' compensation insurance coverage has been in place for this period, and reimbursement for this period has not been previously requested. Interruption dates: From: Reinstated on: Employer signature Date To: For department use only Gross wages $ X 50% = Reimbursement $ Department approval Interruption extended to: Date Signature 440-2968 (2/12/DCBS/WCD/WEB) Date American LegalNet, Inc. www.FormsWorkFlow.com How do I get paid? There is an end date listed at the bottom of page 2 of the Wage Subsidy Agreement. You have to request all your reimbursements no later than one year after that end date. When we approved the Wage Subsidy Agreement, we sent you a copy of the agreement and one Wage Subsidy Reimbursement Request form. If you need more than one form, please make copies of the one we sent you. When you want to get reimbursed for the gross wages you paid the worker, complete and sign the front of this form and send it to us along with the worker's payroll records. Most employers fax this to us at 503-947-7581, but you can also mail or even hand-deliver it. Payroll records need to include the worker's name, the pay period, the wage rate, and the worker's gross wages. If the payroll period is outside the start or end dates of the approved wage subsidy, we will prorate the wages and make sure you get your correct reimbursement. A wage subsidy can be interrupted once for a "reasonable" cause. Examples include the worker being sick, illness in the family, or having a baby. Most reasons would be considered "reasonable" except for the worker just not wanting to work. If there is a layoff, it must last at least 10 consecutive workdays. There is a box on the front of this form to complete for an interruption. The Wage Subsidy Agreement is extended by the number of days of the interruption. We will call you if we have any questions about what you send us. We want to make sure you get all the money you are entitled to. If you have any questions about the wage subsidy or reimbursement, call the Preferred Worker Program at 800-445-3948. American LegalNet, Inc. www.FormsWorkFlow.com