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Get 003me 2016-2024

Lar employee exists, report the limited available wages earned by the injured employee prior to the injury. The wage information on this form is for: The Injured Employee OR A Similar Employee (Note upon Division request, the employee and/or Non-Claim Employer shall identify the similar employee whose wages were provided) NON-CLAIM EMPLOYER WAGES (ONLY THOSE THAT ARE REPORTABLE FOR FEDERAL INCOME TAX PURPOSES) -Indicate the Gross Wages Reportable for Federal Income Tax Purposes earned in t.

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