Louisiana Administrative Code
Title 40 - LABOR AND EMPLOYMENT
Part I - Workers' Compensation Administration
Subpart 3 - Hearing Rules
Chapter 66 - Miscellaneous
Subchapter E - Forms
Section I-6657 - Employee's Monthly Report of Earnings ; Form LDOL-WC-1020

EMPLOYEE CERTIFICATION

I certify that I can read the English language, that I have this entire document and understand its contents, and that I understand I am held responsible for this information. I certify my answers are complete and true, and certify my compliance with the Louisiana Workers' Compensation Act.

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PRINT NAME SIGNATURE SOCIAL SECURITY NUMBER

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ADDRESS CITY STATE / ZIP PHONE NUMBER

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EMPLOYER NAME DATE