Fill and Sign the Georgia Wage Form

Employee Name      Soc. Security No.       Address       Date of Injury                         County of Injury       Employer Name       Address                         employee in the same employment, and write the name of the similar employee here:       Hours Worked      per day per week Worked Per Week                                                Hour Day                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               GEORGIA STATE BOARD OF WORKERS' COMPENSATION WAGE STATEMENT A. IDENTIFYING INFORMATION City State Zip COMPUTATION OF AVERAGE WEEKLY WAGE B. If the weekly benefit is less than the maximum, complete the schedule below for thirteen (13) weeks immediately preceding the accident. If the employee has not been in your employ for the thirteen (13) weeks, complete this schedule showing gross weekly earnings of a similar Also use to establish wage loss for temporary partial disability payments. Number of Days Wage at Date of Injury Change in Hourly Rate$ per On to $ pe r On to $ pe r SCHEDULE OF WEEKLY EARNINGS (Year) Gross No. of Amount Paid Value of Additional Compensation Week Week Days Total No. From To Including Worked Overtime orExtra Work Earnings Date Date Meals Lodging Rent Tips Other 1 2 3 4 5 6 7 8 9 10 11 12 13 Total Average Weekly Earnings REMARK'S: By : (Type or Print and Sign) (Date) Phone Willfully making a false statement for the purpose of obtaining or denying benefits is a crime subject to penalties of up to $10,000.00 per violation (O.C.G.A. §34-9-1 8 and §34-9-1 9). FORM WC-6 REV. DATE 7/2000 6 WAGE STATEMENT