Maine > Workers Compensation
Wage Statement WCB-2 - Maine
| Wage Statement Form. This is a Maine form and can be used in Workers Compensation . |
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STATE OF MAINE WORKERS' COMPENSATION BOARD 27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027 ,1685(5 ),/( 180%(5 (03/2<(5 1$0( 62&,$/ 6(&85,7< 180%(5 /$67 ',*,76 (03/2<(( /$67 1$0( :&% ),/( 180%(5 ),567 1$0( 0, WAGE STATEMENT [[[ [[ (03/2<(5 0$,/,1* $''5(66 $1' 3+21( 180%(5 $''5(66180%(5 $1' 675((7 ,1685(5 1$0( &,7< 67$7( =,3 +20( 3+21( ,1685(5 0$,/,1* $''5(66 '$7( 2) ,1-85< '(6&5,37,21 2) ,1-85< '2(6 (03/2<(( :25. &21&855(17/< )25 $127+(5 (03/2<(5" ,) <(6 *,9( 1$0(6 BBBBBBBBBBBBBBBBBBBBBBBBBBBB 127( 7+( (03/2<(5 6+$// 68%0,7 $ :$*( 67$7(0(17 )25 ($&+ $'',7,21$/ (03/2<(5 :. &200(176 :((. (1',1* *5266 ($51,1*6 :. <(6 12 20. LIST GROSS EARNINGS FOR EACH WEEK: '2(6 (03/2<(( 5(&(,9( )5,1*( %(1(),76 7+$7 0$< 6723 :+,/( 21 :25.(56¶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¶ &RPSHQVDWLRQ %RDUG 7HOHSKRQH RU 77< 0DLQH 5HOD\ :&% HII American LegalNet, Inc. www.FormsWorkFlow.com
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