This is a South Dakota form that can be used for Workers Compensation.
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South Dakota Department of Labor MEMORANDUM OF PAYMENT Division of Labor and Management F OR R EHABIL ITATION Claim Administrator Information: Claim Administrator Federal ID No _________________________ Carrier Code ______________ Claim # ______________ Name (DBA) _____________________________________________ Address ________________________________________ City _______________________ State _______ Zip ____________ Telephone Number _______________________ Form Completed By ______________________________________________ Employer Information: Employer Federal ID No ________________________ Employer Name (DBA) ______________________________________ Employee/Inj ury Information: Employee/Claimant SSN __________________________ Date of Injury _______________________ Body Part(s) Injured ________________ ________________ _______________ ______________ Employee/Claimant Name ______________________________________ ____________________________ _______ ( Last) ( First) ( MI) R etr aining/R ehabilitation Infor mation: Claimants Gross Average Weekly Wage _________________________ Claimants compensation rate is $ _______________________________ Compensation to be paid for rehabilitation (SDCL 62-4-5.1) is $ __________________________ The compensation is based on the following information: The employee is unable to return to his/her usual and customary occupation as of _______________________________ The program of retraining will begin on _________________________ and end on ______________________________ The program of rehabilitation will begin on ________________________________ The program to be undertaken is as follows: (Give a brief description of the program) __________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ If additional medical treatment is required in the future as a result of such injury, the employer/insurer shall be obligated to pay such future medical expenses. This memorandum is a receipt only. It does not constitute an agreement, stipulation or release. The Division of Labor and Management retains jurisdiction as to all issues. The employee does not waive his/her right to pursue any benefits to which he/she may be entitled. Claimant/Employee Signature ______________________________________________________ Date __________________ Claim Administrator Signature _____________________________________________________ Date __________________ Division of L abor and Management Approval by ___________________________________________ Date _____________ Submit form to: South Dakota Department of Labor Division of Labor and Management 700 Governors Drive DOL-LM-113 Revised 06/06/2003 Pierre, SD 57501-2291 Telephone (605)773-3681