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Wage Statement C-41 - Tennessee

Wage Statement Form. This is a Tennessee form and can be used in Workers Compensation .
 Fillable pdf Last Modified 9/25/2008
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FORM C-41 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers Compensation Nashville, Tennessee 37243-0661 WAGE STATEMENT It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers compensation transactionfor the purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits. EMPLOYEE:________________________SSN:_________________STATE FILE #_______________ In order to determine the correct rate of compensation to be paid to the above injured party, please fill in the schedule below andreturn it promptly. This information is required by law and no agreement for payment of compensation can be made until it has beenreceived. Please complete 52 weeks prior to date of accident. Please describe allowances of any character made in lieu of wages that must be deemed a part of employees earnings:__If the average weekly wage is not based on fifty-two weeks of earnings proceeding the date of injury, please show your computationbelow:____________________________________________________________________________ WEEK NO. DAYS WEEK ENDING GROSS WEEK NO. DAYS WEEK ENDING GROSS WAGES WAGES 12 7 22 8 32 9 43 0 53 1 63 2 73 3 83 4 93 5 10 36 11 37 12 38 13 39 14 40 15 41 16 42 17 43 18 44 19 45 20 46 21 47 22 48 23 49 24 50 25 51 26 52 TOTAL PAID RATE PER DAY _____________PER HOUR________________ AVERAGE PER WEEK _______________ I hereby certify that the above is a true and correct account, as taken from our timebooks or pay-roll records, of the wagespaid to the above-named injured employee for the periods indicated. Date ______________20 ____ EMPLOYER BY ______________________________________________ TITLE ______________________________________________ LB-0384 (rev. 8/99)
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