LB-0384 (REV 11/15) RDA 10183 220 French Landing Drive, I-B Nashville, TN 37243-1002 FORM C-41 WAGE STATEMENT EMPLOYEE: SSN: STATE FILE #: Employer Ins Claim # Date of Injury: Please list the wages earned by the employee named above during each of the 52 weeks prior to date of injury, if applicable. WEEK WEEK ENDING GROSS WEEK WEEK ENDING GROSS WAGES WAGES 1 27 2 28 3 29 4 30 5 31 6 32 7 33 8 34 9 35 10 36 11 37 12 38 13 39 14 40 15 41 16 42 17 43 18 44 19 45 20 46 21 47 22 48 23 49 24 50 25 51 26 52 TOTAL PAID Date: Name of Preparer and Title American LegalNet, Inc. www.FormsWorkFlow.com