Minnesota > Workers Comp
Notice Of Penalty Payment NO0015 - Minnesota
| Notice Of Penalty Payment Form. This is a Minnesota form and can be used in Workers Comp . |
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Minnesota Department of Labor and Industry Financial Services 443 Lafayette Road North St. Paul, MN 55155-4310 (651) 284-5359 or (800) 342-5354 NO0015 DO NOT USE THIS SPACE Notice of Penalty Payment Attach this to the ARSA payment and mail to the above address SOCIAL SECURITY NUMBER DATE OF INJURY EMPLOYEE EMPLOYER INSURER/ADJUSTING COMPANY INSURER/ADJUSTING COMPANY CLAIM NUMBER PENALTY NUMBER SERVED AND FILED TO BE FILLED OUT BY PAYOR (Check one or both) This is to certify that the above-captioned employee was paid the $ penalty assessment in accordance with M.S. 176.225 on (date) This is to certify that the $ for deposit in the Assigned Risk Safety Account. penalty assessment was paid to the Commissioner Payor's Signature Date Printed Name and Title Phone Number Online payment is now available at: www.doli.state.mn.us/paycenter For online payment assistance call: Department of Labor and Industry, Financial Services at 651-284-5021 Department of Labor and Industry Federal Tax ID # 41-6007162 MN NO0015 (8/05) American LegalNet, Inc. www.USCourtForms.com
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