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Get TX DWC Form-003 2005-2024

Rk Status and Post-Injury Earnings. Name and Phone # of Person Providing Wage Information: I HEREBY CERTIFY THAT this wage statement is complete, accurate, and complies with the Texas Workers' Compensation Act and applicable rules, and the listed wages include all pecuniary and nonpecuniary wages paid for (earned in) the 13 weeks prior to the date of injury (as described on page 2) and I understand that making a misrepresentation about a workers’ compensation claim is a crime that can result.

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