Certificate Of Dependency And Employee Exemption Report
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Certificate Of Dependency And Employee Exemption Report Form. This is a Vermont form and can be use in Workers Compensation.
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Tags: Certificate Of Dependency And Employee Exemption Report, 10-10s, Vermont Workers Compensation,
DOL FORM 10/10s
(Rev. 9/09)
State File No.**
Ins. Co. File No.
Date of Injury
Fed. ID No.
DEPARTMENT OF LABOR
WORKERS’ COMPENSATION DIVISION
CERTIFICATE OF DEPENDENCY AND EMPLOYEE EXEMPTION REPORT
EMPLOYEE:
EMPLOYER:
TO THE EMPLOYEE: This form MUST be completed in every workers' compensation case in which an injured worker has lost time from
work as the result of a work-related injury. The form must be completed even when the injured worker has no dependents. The information must
be supplied and the form signed by the injured worker. This information is required by the Department of Labor to determine the employee's
right to additional weekly compensation of $10.00 for each dependent child under the age of twenty-one (21) years.
PART A:
FILING STATUS – Select One: [For purposes of determining Earned Income Credit (EIC)]
Single
Married or Civil Union
PART B:
List below your dependent child(ren) that have not already been declared by your spouse or reciprocal beneficiary on his/her current workers'
compensation claim, the child's date of birth, and their relationship to you.
NAME OF DEPENDENT
DATE OF BIRTH
RELATIONSHIP
1.
2.
3.
4.
5.
I HEREBY CERTIFY that the above is a true, complete and accurate statement of my dependents.
Employee Signature
Address
Telephone Number
City/State
**If you do not have your state file number please contact the Department of Labor at (802) 828-2286
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