DOL FORM 25s (Rev. 9/09) State File No. Ins. Co. File No. Date of Injury Fed. ID No. DEPARTMENT OF LABOR WORKERS' COMPENSATION DIVISION WEEKLY NET INCOME WORKSHEET EMPLOYEE: EMPLOYER: PLEASE COMPLETE THE FOLLOWING TO DETERMINE THE WEEKLY NET INCOME AS DEFINED IN 21 V.S.A. § 601(21). NOTE: Lines 1 through 13 must be completed for both years when wages are paid in two different years as noted on the Wage Statement. To determine the weekly net income when wages are included for two different years, multiply the result on line 13 by the number of weeks on line 2 for each year. Combine the totals for each year and divide by the total number of weeks used for both years. 1. 2. 3. 4. Enter the total "GROSS" wages found on the Wage Statement (Form 25). Enter the number of weeks used to determine the total "GROSS" wages on the Wage Statement (Form 25). Divide line (a) by line (b) to determine the average weekly wage (A.W.W.). Enter the Standard Federal Income Tax Deduction to which the employee is entitled (see I.R.S. Circular E). This may differ from what is actually being deducted. NOTE: Use A.W.W. to calculate. Subtract line (d) from line (c). Enter. Enter the Standard State Income Tax Deduction to which the employee is entitled (see VT Income Tax Withholding Tables). This may differ from what is actually being deducted. NOTE: Use A.W.W. to calculate. Subtract line (f) from line (e). Enter. Enter the Standard Social Security Tax to which the employee is entitled (see I.R.S. Circular E). This may differ from what is actually being deducted. NOTE: Use A.W.W. to calculate. Subtract line (h) from line (g). Enter. Enter the appropriate Medicare Tax deduction (see I.R.S. Circular E). NOTE: Use A.W.W. to calculate. Subtract line (j) from line (i). Enter. Enter any Earned Income Credit (EIC) to which the employee is entitled (see I.R.S. Circular E). NOTE: Use A.W.W. to calculate. Add line (k) and line (l). Enter. This is the employee's WEEKLY NET INCOME. $ (a) (b) $ (c) $ $ (d) (e) 5. 6. $ $ (f) (g) 7. 8. $ $ $ $ $ $ (h) (i) 9. 10. 11. 12. 13. (j) (k) (l) (m) American LegalNet, Inc. www.FormsWorkFlow.com