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Wage Statement (Report Of Employees Wages) Form. This is a Vermont form and can be use in Workers Compensation.
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Tags: Wage Statement (Report Of Employees Wages), 25, Vermont Workers Compensation,
DOL FORM 25
STATE OF VERMONT
Department of Labor
Workers’ Compensation
5 Green Mountain Drive, PO Box 488
Montpelier, VT 05601-0488
(Rev. 6/10)
State File No.**
Ins. Co. File No.
Date of Injury
Fed. ID No.
WAGE STATEMENT – For Injuries on or after July 1, 2008
Employee:
Employer:
Wage Rate:
$
per
Week Ending
Month
Day
Year
Number of Days
Hired to Work:
Number
of
Hours
or Days
Worked
Gross Wages
Number of Hours Hired to Work:
Extras (as in 6 or 7)
Please indicate what the
extra is, for example,
$1000.00 bonus
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?
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 where the
employee had excused absences for
which he/she was not paid for more
than ½ of a work week.
4. Leave blank those weeks where you
had reduced operations or a shutdown
of the plant for which he/she was not
paid for more than ½ of a work week.
5. Do not enter those weeks where an
employee was on vacation for more
than ½ of a work week.
6. If room, board, lodging or other
“extras” (electricity, fuel, etc.) are
provided in addition to monetary
wages, break it down into a weekly
value, include and describe this
income in column marked “EXTRAS.”
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 “EXTRAS.”
8. Enter the dates when your normal
work week ends (not the date a check is
given to the employee) and the number
of hours or days worked.
Was the employee paid in full for the day of the accident?
Are employee’s wages subject to any child support withholding order?
If yes, in what amount?
$
Yes
per
No
Day of the week the check will be mailed to the claimant or deposited in the claimant’s account
This is a correct statement of the employee’s earnings as taken from the employer’s payroll records.
By:
Position Title:
Signature of Preparer
Print Name:
Date:
**If you do not have the state file number please contact the Department of Labor at (802) 828-2286.
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