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Fill and Sign the Claim of Unpaid Wages State of South Dakota Form

Fill and Sign the Claim of Unpaid Wages State of South Dakota Form

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Open the document and fill out all its fields.
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Workers’ Compensation Expenditure Report for _______________ BBB_____ ______Lump Sum ___ ___ ___ ___ ___ _ _____ ___ ___ ____ _ _____ ___ ___ Date of Fata lity: _ _____ ___ ___ ___ N o. of Weeks Paid Amount Paid ____________ ________________ ____________ ________________ Amoun t Paid _ __ ___ ___ ___ ___ _ __ ___ ___ ___ ___ _ __ ___ ___ ___ ___ _ __ ___ ___ ___ ___ _ __ ___ ___ ___ ___ _ __ ___ ___ ___ ___ _ __ ___ ___ ___ ___ _ __ ___ ___ ___ ___ _ __ ___ ___ ___ ___ _ __ ___ ___ ___ ___ _ __ ___ ___ ___ ___ _ __ ___ ___ ___ ___ _ __ ___ ___ ___ ___ MI SCELLA NEOU S EXPE NSES: 402- Interes t to Claimant 404 – Deducti ble Reimbursement 112 - Inv est ig at ive Fees 111 - Le gal Fees 403 - Pena lty Ch arged to Employ er 114 - Rehabilitati on Consultant 401 - Sub roga tion 117 – Ca se Man agemen t F ees 116 - Misc ella neous Expenses (please specify) Amount Paid ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ 312 - Fatality Payments 311 - Fatality Settlement/Lump Sum MEDICAL EXPENSES : 102 – Chiropractor 113 - Counseling Services 103 – Dentist 104 - Doctor 105 - Equipme nt 115 - Home Health Care 101 - Hospital 106 - Pharmacy 110 - Physical Therapy Fees DLR -LM -107 Revised 02/06/2017 SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATION DIVISION OF LABOR AND MANAGEMENT 123 W. Missouri Ave. Pierre, South Dakota 57501 Tel: 605.773.3681 Fax: 605.773.4211 dlr.sd.gov MONTHLY PAYMENT REPORT 31 3 - Transportation & Burial Expenses SD EForm - 2208 V1

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