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Gency Estimate of FECA Entitlement: A. Weekly Base Payrate (excluding overtime) Date of Injury / / $ Date Stopped Work / / $ Date of Recurrence / / $ Enter the greatest amount and the effective date of that amount on line 1. 1. / / (effective date) B. Additions to Base Pay: If employee works a regular schedule, state the amount earned weekly. If irregular schedule, state amount earned 1 year prior to date entered on line 1 by 52. Night Differential 2. Sun.

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