Wage Verification Form

Please Let the following serve as verification of lost wages:

Employee: _____________________________________

Date of Loss: ____________________________________

Company Name: _________________________________

My Name: ______________________________________

My Job Title: ____________________________________

Employee has:

• Been employed with our company since: ______________________________

• ____________________________ has missed __________________ (circle one) hours - days - weeks - months, including vacation time or sick leave, of work due to this accident.

• On the date of the accident, employee was paid as follows: ______________per hour - week - month (circle one).

• On the date of the accident, the employee worked approximately ____________ hours per day - week - months (circle one).

          As of today, the employee, _________________________________________ has lost a total of $ __________________ in wages due to the said accident including calculated sick leave and vacation time traceable to this accident.

Signed this ___________day of _____________, 20___

Supervisor's Signature ___________________________

Printed Name _________________________________

Company Name _______________________________

Company Telephone ____________________________

Company Address _______________________________

Please Return this form to:
The Law Offices of Richard Pena, P.C.
2028 East Ben White, Suite 220
Austin, Texas 78741

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