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Statement Of Wages (For Injuries Occurring On Or Before June 23 1996) Form. This is a Pennsylvania form and can be use in Workers Comp.
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Tags: Statement Of Wages (For Injuries Occurring On Or Before June 23 1996), LIBC-494A, Pennsylvania Workers Comp,
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF LABOR AND INDUSTRY
BUREAU OF WORKERS' COMPENSATION
COURT
1171 S. CAMERON STREET, ROOM 103
HARRISBURG, PA 17104-2501
COUNTY .OF. . . . . . . . . . .FOR .INJURIES OCCURRING.
......... ..
... .................
(TOLL FREE) 800-482-2383
Social Security Number:
STATEMENT
OF WAGES
Date of Injury:
MM
DD
YYYY
. . . . . .PA BWC Claim Number:
...
ON OR BEFORE JUNE 23, 1996
:
Index No.
Employee
(IF KNOWN)
Employer
Name
Last Name
Street 1
Plaintiff(s)
Street 2
:
Calendar No.
Street 1
First Name
:
JUDICIAL SUBPOENA
Street 2
-againstCity/Town
State
FEIN
:
Zip Code
City/Town
State
Zip Code
:
THE FOLLOWING WAGE INFORMATION MUST BE COMPLETED IN ACCORDANCE WITH SECTION 309 OF THE PENNSYLVANIA
:
WORKERS' COMPENSATION ACT, THE ORIGINAL ATTACHED TO NOTICE OF COMPENSATION PAYABLE OR AGREEMENT FOR
COMPENSATION FOR DISABILITY OR PERMANENT INJURY AND SENT TO THE BUREAU. A COPY IS TO BE SENT TO EMPLOYEE.
Defendant(s)
:
..
. . . . . . . . . . . . . . . . . . items . . . . . . . . . . . . . . . . . . . .
Computation: . . . Compute.the.appropriate . . . . . below for. the.employee. .The. highest result of the computations is used to determine the average weekly wage to be used to establish the basis for workers' compensation payments.
1.
If wages fixed by:
$
(a) Week
THE PEOPLE OF THE STATE OF NEW YORK
(b) Month $
times 12 divided by 52 = $
(c) Year $
TO
2.
divided by 52 = $
494A 1297-1
If wages fixed by day, hour, or output, including overtime and bonus, then complete the following for each of the four 13-week
periods prior to the date of injury:
FROM
GREETINGS:
TO
1st Period
BOARD*
LODGING*
WAGES
$
$
GRATUITIES**
$
TOTAL.
DAYS
WORKED
$
WE COMMAND YOU, that all business and $
excuses being laid aside, you and each of you attend before
$
$
$
,
at the
Court
$
$
$
$
located at
County of
$
$
$
$
4th Period
in room
, on theInclude at actual value of board and/or lodgingat
day of
, 20
,
o'clock in the
noon, and at any recessed
*
** Include employee receives at least one-third this action or the part
or adjourned date, to testify and ifgive evidence as a witness in of wages in tipson gratuities of the
2nd Period
the
3rd Period Honorable
(a) Using the highest 13-week period from above:
$
divided by 13 weeks
=$
(b) Last two completed 13-week comply with this subpoena is punishable as a contempt of court and will make you liable to
Your failure to periods:
$ the party on whose behalf this subpoena was issued days employee worked multiplied by all damages sustained as a
total wages divided by
total for a maximum penalty of $50 and 5
=$
3.
result of than one 13-week period:
If employed lessyour failure to comply.
$
total wages divided by
total days employee worked times
total days worked
Witness, Honorable
, one divided by 13
by other employees in a similar occupation for the quarter immediately preceding the injury of the Justices of the$
=
Court is exclusively seasonal:
in
County,
day of
, 20
4. If occupation
$
total wages from all occupations during 12 calendar months preceding injury divided by 50
=$
For the following two methods, use calendar quarters (i.e. January through March, April through June, July through
(Attorney must sign above and type name below)
September, October through December):
total wages earned with the same employer during the last two complete calendar quarters
$
5.
6.
divided by the
$
number of days worked for the employer during that period multiplied by 5
Attorney(s) for
wages under Section 309(f) are computed using the calendar quarters as defined above.
=$
The highest calendar quarter wages received in the first four of the last five completed calendar quarters
immediately preceding the date of injury is $
divided by 13
=$
BASED ON ABOVE INFORMATION, THE HIGHEST AVERAGE WEEKLY WAGE FOR INJURED EMPLOYEE IS
Office and P.O. Address
COMPENSATION PAYABLE: $
Name of Insurer or Third Party Administrator (if self-insured):
$
PER WEEK
Phone
Name of Employer/Insurer Representative:
Bureau Code
Telephone No.:
Facsimile No.:
Any individual filing misleading or incomplete information knowingly and withE-Mail Address: is in violation of Section 1102 of the
intent to defraud
Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of
Mobile Tel. No.:
Signature of Employer/Insurer Representative:
1994.
LIBC-494A
REV 12-97
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