Completed by injured workers contending eligibility for payment of back time loss benefits for a period that exceeds six months or $25,000. Injured workers requesting benefits for current time missed from work due to a work-related injury should use the F242-052-000 Worker Verification Form.

Affidavit_for_Time_Loss_Compensation_Benefits Spanish DECLARACIÓN FIRMADA PARA COMPENSACIÓN DE TIEMPO PERDIDO Completed by injured workers contending eligibility for payment of back time loss benefits for a period that exceeds six months or $25,000. Injured workers requesting benefits for current time missed from work due to a work-related injury should use the F242-052-999 Worker Verification Form.

Used by employers with no employees or worker hours to report but need an open account for contract bidding process.

Completed by the injured worker if they are unable to work due to a workplace injury AND their employer is not paying their full wages.

State fund workers who have selected Option 2 and closed their claim can use this form to apply for access to their Option 2 training funds. To seek reimbursement, use form F245-030-000 Statement for Retraining and Job Modification Services.

Crime Victim Worker Verification - Spanish FORMULARIO DE VERIFICACIÓN DE EMPLEO

Used by the student and a school official each quarter to verify school enrollment.

Use by the student and a school official each quarter to verify school enrollment.

For use by crime victims requesting time-loss compensation

Completed by the injured worker if they are unable to work due to a workplace injury AND their employer is not paying their full wages.