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Ed or unemployed, both the Wage Built with you in mind. Statement and the affidavit must be completed. FAILURE TO FILE WAGE STATEMENTS MAY DELAY OR STOP COMPENSATION. The affidavit below may be sworn to without cost before a deputy in a Date of injury WAGE STATEMENT Claim number local customer service office of the Bureau of Workers' Compensation. Injured Worker's name Employer name Telephone number If you are applying for Wage Loss benefits, please include FROM and TO dates. TO FROM If e.

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