De p artment of Labor, Workers222DOL FORM 25 ( Rev. 1/2018 ) Workers222 CompensationPO Box 488State File No. Mont p elier, VT 05601-0488Ins. Co. File No. ( 802 ) 828-2286; TDD 800-650-4152Date of In j ur y www.labor.vermont.gov Fed. ID No. WAGE STATEMENT 226 For in j uries occurrin g on or after Jul y 1, 2008 Employee: Em p lo y er: Wage Rate: $ p e r Number of Days Hired to Work:Number of Hours Hired to Work: Week Ending Number of Hours or Days Worke d Gross Wages Extras (as in 6 or 7) Please indicate what the extra is, for example, $1000.00 bonus INSTRUCTIONS: Read Carefully 1. Enter GROSS wages of employee for 26 weeks before date of accident (NOT take-home pay). 2. Do not include the week of the accident. 3. Leave blank those weeks in which the employee had excused absences for which he/she was paid for less than 275 of a work week. 4. Leave blank those weeks in which you had reduced operations or a plant shutdown and for which the employee was paid for less than 275 of a work week. 5. Do not enter those weeks in which an employee was on vacation for more than 275 of a work week. 6. If room, board, lodging or other 223extras224 (electricity, fuel, etc.) are provided in addition to monetary wages, break these down into a weekly value, and include and describe the income in the column marked 223EXTRAS.224 This includes tips if not included in gross wages. 7. Include any bonuses and commissions paid to the employee in addition to wages in the column marked 223EXTRAS.224 8. Enter the dates when your normal work week ends (not the date a check is issued to the employee) and the number of hours or days worked. Month Day Year 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 When did the employee begin losing time? Was the employee paid in full for the day of the accident? Are em p lo y ee222s wa g es sub j ect to an y child su pp ort withholdin g order? Yes No If yes, in what amount? $ p e r Da y of the week the check will be mailed to the claimant or de p osited in the claimant222s account This is a correct statement of the em p lo y ee222s earnin g s as taken from the em p lo y er222s p a y roll records. B y : Position Title: Signature of Prepare r Print Name: Date: American LegalNet, Inc. www.FormsWorkFlow.com