Pennsylvania > Workers Comp
Employees Report Of Benefits LIBC-756 - Pennsylvania
| Employees Report Of Benefits Form. This is a Pennsylvania form and can be used in Workers Comp . |
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COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800-482-2383 Index No. Calendar No. MM DD YYYY JUDICIAL SUBPOENA (IF KNOWN) EMPLOYEE'S REPORT OF BENEFITS (UNEMPLOYMENT COMPENSATION, SOCIAL SECURITY [OLD AGE], SEVERANCE AND PENSION BENEFITS) Plaintiff(s) Social Security Number: : Date of Injury: : : -againstEmployee First Name Street 1 Street 2 Last Name FOR OFFSETS PA BWC Claim Number: Employer Name Street 1 Street 2 : : Defendant(s) : . .. . .. ..... City/Town . . . . . . . . . . . . . . . . . . . . . . State. . . . Zip.Code . . . . . . . . . . . . . . . City/Town . County Telephone County Telephone State Zip Code THE PEOPLE OF THE STATE OF NEW YORK READ THE INSTRUCTIONS ON THE REVERSE SIDE BEFORE COMPLETING THIS FORM. TO Section 204 of the Workers' Compensation Act requires employees receiving wage loss benefits to report the receipt of unemployment compensation, GREETINGS: social security (old age) benefits, severance and pension benefits. FEIN Insurer or Third Party Administrator (if self-insured) Name Street 1 Street 2 City/Town State Zip Code WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before COMPLETE AND RETURN THIS FORM TO THE Bureau Code , the Honorable at the Telephone Court INSURER OR of SELF-INSURED EMPLOYER located at County County IDENTIFIED ON THIS FORM. in room , on the day of , 20 , at o'clock in the noon, and at any recessed Claim Number FEIN or adjourned date, to testify and give evidence as a witness in this action on the part of the Complete the following information, indicating the type, amount and frequency (i.e.: weekly, biweekly , or other (specify)) of the benefits being received. Include the date such receipt began and ended (if applicable). If you are not receiving a particular type of Your failure to comply with this subpoena is punishable as benefit, indicated by writing "not applicable" or "none" in the appropriate space. a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Amount Receipt Began Receipt Ended result of your failure Received to comply. Type of Benefit Date Date Frequency (MM/DD/YYYY) (MM/DD/YYYY) Gross $ Unemployment Net $ Witness, Honorable Compensation Social Security (old age) Severance Pension Weekly Other Biweekly , one of the Justices of the Biweekly Biweekly (Attorney must sign above and type name below) Biweekly Court in Gross $ Net $ Gross $ Net $ Gross $ Net $ County, day of Weekly Other Weekly Other Weekly Other , 20 If you are receiving pension benefits from the employer directly liable for your workers' compensation, indicate the percent of the pension which is funded by the employer or check the box for 'percentage unknown'. % Percentage Unknown Attorney(s) for Did you "rollover" pension benefits into an IRA Account? Yes No Amount "rolled Office and P.O.over" $ Address (IRA benefits are not offset until you begin withdrawing them from your account.) I verify that this information is true and correct, based upon my knowledge, information and belief. I understand false statements are subject to the penalties of 18 Pa. C.S . §4909, relating to unsworn falsification to authorities. DAT Telephone No.: Facsimile No.: EMPLOYEE SIGNATURE MM DD YYYY If you are receiving any wages from employment or self-employment, checkE-Mail Address: must report this to your insurer or this box . You Mobile Tel. self-insured employer . Contact your insurer/employer for that reporting form (LIBC-760). No.: (OVER) LIBC-756 REV 12-97 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. LIBC-756 Calendar No. INSTRUCTIONS : Plaintiff(s) TO EMPLOYEES: JUDICIAL SUBPOENA -against- : If you are receiving workers' compensation wage-loss benefits due to an injury which occurred on or after June 24, 1996, you must report the receipt of the following: : · · · · Unemployment Compensation Benefits Social Security (Old Age) Benefits : Defendant(s) : ...................................................... Severance Benefits paid by the employer directly liable for your workers' compensation Pension Benefits to the extent funded by the employer directly liable for your workers' compensation. THE PEOPLE OF THE STATE OF NEW YORK Your workers' compensation benefits may be adjusted if you are receiving any of the above benefits. You are required to TO acknowledge both the receipt of and changes to any of the benefits listed above through the immediate completion and submission of this form. FAILURE TO REPORT THE RECEIPT OF OR CHANGES TO ANY OF THE BENEFITS LISTED ABOVE MAY YOU GREETINGS: TO PROSECUTION UNDER ARTICLE XI OF THE WORKERS' COMPENSATION ACT RELATING TO INSURANCE FRAUD. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Your failure Pennsylvania Act 165 of 1994.to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. , one of the Justices of the day of , 20 Witness, Honorable Court in County, (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com
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