Form 25M WORKERS COMPENSATION DIVISION 5 GREEN MOUNTAIN DRIVE, PO BOX 488 MONTPELIER, VT 05601-0488 (802) 828-2286 State File No.: Ins. Co. File No.: Date of Injury: Rev. 1/15 www.labor.vermont.gov This form shall be filed whenever a claimant has received or is eligible to receive 90 days of temporary total disability [see Title 21 §641(a)(3)]. These are not consecutive days but cumulative. Failure to file this form promptly and accurately may result in administrative sanctions pursuant to Rule 45.000. In lieu of a screening a referral for vocational rehabilitation entitlement may be filed. This form MUST be filed with a copy of the referral form (VR1). MEMORANDUM OF PAYMENT Employee Last Name: Mailing Address: Telephone Number: First Name: City: State: Zip: Employer Employer Name: Employer Address: Insurer: Employer Telephone Number: Payment Made Weekly Compensation Date Disability Payment Began: Total Amount of Indemnity Paid To Date: Other: (Please Explain) Weekly Amount Paid: ISSUED BY: Carrier: Adjuster Name: Adjuster Signature: Adjuster License #: Vocational Rehabilitation Referral filed with: Name of Vocational Rehabilitation Counselor Company Responsible for Payment: Mailing Address: City: State: Zip: Administrator (if not carrier): Telephone No.: Adjuster's Employer: American LegalNet, Inc. www.FormsWorkFlow.com