The Pennsylvania Statement of Wages (For injuries Occurring On or Before June 23, 1996) is a form used by employers in the state of Pennsylvania to provide a detailed record of an employee's wages for a period of disability due to a work-related injury that occurred on or before June 23, 1996. This form is part of the Pennsylvania Workers' Compensation Act and must be completed and filed with the Pennsylvania Department of Labor and Industry. The form provides information on the employee's wages, including gross pay, deductions, and net pay. It also provides information on the type of injury, the date of the injury, the date of incapacity, and the employee's average weekly wage. The Pennsylvania Statement of Wages (For injuries Occurring On or Before June 23, 1996) is available in two forms: the "Original Statement of Wages" and the "Final Statement of Wages". The Original Statement of Wages is to be completed by the employer and submitted to the Department of Labor and Industry for review. The Final Statement of Wages is a revised form to be completed by the employer and submitted to the Department of Labor and Industry for final review and approval. Both forms are available from the Pennsylvania Department of Labor and Industry website.