LOST WAGES/EARNINGS CLAIM FORM - LCLE
Disability Dates MUST be filled in. Proof of income. Two or three payroll check stubs for the periods immediate prior to the crime. If payroll check stubs are not possible, or if the victim was self-employed, submit a copy of the previous year's federal income tax return . If lost wages reimbursement is being claimed to take a child to a medical or mental health provider, … ................
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