Fill and Sign the Filing Status and Exemption Connecticut Form

B. Head of Household D. Married, filing separately WCC FILE #       Name:             Address:       2. How many exemptions (include yourself) did you list on your last Federal and State Tax Returns?       legally blind spouse - 65 years of age or older spouse - legally blind 1 .       2.       3.       4.       5.       6.                                                                         Other Employers: Names       Addresses             Weekly hours:       Weekly wages:       Date of hire:       Are you currently working:       Type of Work Performed:             1A State of Connecticut Workers' Compensation Commission FILING STATUS AND EXEMPTION FORM THIS FORM MUST BE EXECUTED IN EVERY CASE OF COMPENSABLE DISABILITY, FOR INJURIES OCCURRING ON OR AFTER OCTOBER 1, 1991 SS#: In order for this company to determine your weekly benefit rate, as per Public Act 93-228, an Act concerning comprehensive Workers' Compensation reform, we need the following information: 1 . There are four (4) filing statuses provided. You must select one, based upon your IRS filing status on the date of your injury and the position you took in filing your prior year's Federal and State Tax Returns. (i.e. D.O.I. 6/15/96, last tax return 12/31/95) A. Single C. Married filing jointly 3. Check all appropriate boxes: 65 years of age or older 4. List name (yourself first), date of birth and relationship to you for all exemptions listed on your last Federal and State Tax Returns: (Question #2 above): Name Birth Date Relationship SELF 5. IMPORTANT: To be certain that you receive all the benefits to which you are entitled please provide the following information if you were engaged in any other employment at the time of your injury or are currently engaged in any other employment. If you have no other employment insert the word ''none'' 6. This form must be completed in its entirety. Any person who intentionally misrepresents or fails to disclose any material fact related to a claimed injury may be guilty of a felony. EMPLOYEE'S SIGNATURE DATE Rev.3/16/98 Prior version obsolete