STATEMENT OF WAGES

(A) If the injured person has been in the Employer's service during a continuous period of m l Qhan me
month immediately preceding the accident, tman the wages that have been paid, or fdkn due for
payment t o him in each month of such period (not exceeding twelve preceding month8 in dl),must bc
~ n ~ e r eind the statement.
(B) If the injured person has been in the Employer's smrice for the k s than one m t h , thsm that
be entered in the statement the wt8 paid t o another workman employed on the same kind of work
by the Employcr during the twelve months immediaaaly preceding the accident.
(C) If worker is a daily paid employee. give (a) daily rate of v~agesand (b) number d'days am an averwe
that helshe would work in a month - (a) (b)

TABLE OF WAGES
Please fill in the Table of wages below as applicable to (.A), ( 8 ) or (C)

In colur~ln"Absence" give date of going on leave'or beginning of peried of absenec and also date of
, ,
subsequerlt resumption of work.

The above statement of earnings etc., is to the besf oC my knowledge and belief accurate.

Place :
Dale : Signature -Itf Employer

(Add below any additionai infoinlatioil avaiiablc regarding the accident)

 STATEMENT OF WAGES
(A) If thc injured person has been in the Employer's strvicc during a continuous pdod of WL &an M e
month immediately preceding the wcidcnt, than the w a m that have been paid, or :Wkn due for
payment to him m each month of such period (not e x d i n g twelve preceding month8 in dl),must k
entered in the statement.
(81 If the injured person has bccn in the Employar's sewice for the tess than one month, that must
be entered in the statement the w q e g paid to another workman employed on the same k i d 0f work
by the Employpr during the twelve months immodiatbly preceding the accident.
(C) If worker is a daily paid employee. give (a) daily rate of wages and (b) number d'days am an a v m w
that he!& would work in a month - (a) (b)
TABLE OF WAGES
Please fill in the Table of wages below a6 applicable to (A), (B) or (C)

1 2 3 4 S 6

Month & Basic Pay & OMtimc Bonus Conc~sionin Value 04 free
Yesr md Darmrrs Valuoof quartem ABSf NCE
D. A. Allowana food4tuffs (lOO/a bssic wages)

pp
----

2-
2 .

Total, earnings in the peried

from
to
. .- Average monthly wages

* In colufiln "Absence" give date of going on Icave'or beginning of peried of absence and also date of
, ,
subsequent resumption of work.
The above statement of earnings etc., ir to the best' of my knowlcdpe and belief xccurite:

Signature ef Employer

(Add bclow any additional information avaiiablc regarding the accident.)

- -.