Free Average Weekly Wage Certification - Kentucky

Form AWW-1 Average Weekly Wage Certification Adopted January 1, 1997

KENTUCKY DEPARTMENT OF WORKERS CLAIMS CLAIM NUMBER

PLAINTIFF VS WAGE CERTIFICATION DEFENDANTS

1. 2.

Date of Injury/Exposure as reported on Form 101/102/103: Method of Wage Payment (check one):


3. 4.

Hourly Weekly Salary Yearly Salary


Full-time Volunteer

Daily Monthly Salary Output of Employee

Date of Hire or Employment: Status or Classification of Employment (check one):


5.

Part-time Seasonal



Probationary Apprentice/Trainee

Did Employer provide any of the following (check appropriate ones):


6.

Board Lodging

Rent Fuel

Housing

Did Employee (check appropriate ones):



Work Overtime



Receive Gratuities



Paid Vacations/Holidays

Claimant's Name: Claim Number:

Weeks Worked Month/Day/Year 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

# of Regular Hours Worked + + + + + + + + + + + + +

# of Overtime Hours Worked x x x x x x x x x x x x x

Regular Hourly Rate = = = = = = = = = = = = = Total: ÷ By 13 weeks =

Weekly Wage

$ $ = = = = = = = = = = = = =

14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26.

+ + + + + + + + + + + + +

x x x x x x x x x x x x x Total: ÷ By 13 weeks =

$ $

Claimant's Name: Claim Number:

Weeks Worked Month/Day/Year 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39.

# of Regular Hours Worked + + + + + + + + + + + + +

# of Overtime Hours Worked x x x x x x x x x x x x x

Regular Hourly Rate = = = = = = = = = = = = = Total: ÷ By 13 weeks =

Weekly Wage

$ $ = = = = = = = = = = = = =

40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52.

+ + + + + + + + + + + + +

x x x x x x x x x x x x x Total: ÷ By 13 weeks =

$ $

CERTIFICATION I hereby certify that the above wage information is a true and accurate accounting of the from the date of employment or wages of (claimant's name) fifty-two weeks prior to the date of the injury/last exposure as set forth in the Form 101/102/103, whichever is shorter.

Name of Company

Signature

Title

Date

CERTIFICATE It is hereby certified that the original of this wage certification was mailed this day , 20__ to the Commissioner and a copy of the same to Counsel of record and of the assigned Administrative Law Judge.

Attorney for Defendant Employer