LOST WAGES/EARNINGS CLAIM FORM - LCLE
Proof of income. Two or three payroll check stubs for the periods immediate prior to the crime ... Amounts received per week/month: _____ [ ]Union coverage [ ]Disability insurance [ ]Workers' Compensation [ ]Sick Pay [ ] Vacation Pay [ ]Unemployment [ ]Other, (specify) _____ ... Only a surgeon, medical doctor, oral surgeon, psychiatrist, or an ... ................
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