Permanent Total Disability Report Of Employment {D-14}

PERMANENT TOTAL DISABILITY REPORT OF EMPLOYMENT Pension No. Please provide the earnings information for the periods shown below. Misrepresentation of the information requested is fraud and is a violation of Nevada law. Earnings are defined as wages, including overtime, commissions, salary, vacation, holiday and sick leave, termination pay, bonuses, tips declared for the purpose of receiving workers compensation insurance after July 1, 1985, or other remuneration received from an employer for services rendered. MONTH YEAR AMOUNT OF EARNINGS 1. ____________________________ _________ $_____________________ 2. ____________________________ _________ $_____________________ 3. ____________________________ _________ $_____________________ 4. ____________________________ _________ $_____________________ 5. ____________________________ _________ $_____________________ 6. ____________________________ _________ $_____________________ 7. ____________________________ _________ $_____________________ 8. ____________________________ _________ $_____________________ 9. ____________________________ _________ $_____________________ 10.____________________________ _________ $_____________________ 11.____________________________ _________ $_____________________ 12.____________________________ _________ $_____________________ I hereby declare that the earnings information provided above is correct to the best of my knowledge and that there has been no willful concealment, evasion, or enlargement of that information. Signature Date (Month, Day, Year)Name Social Security No. Address (P.O. Box, Apt., Street) City, State, Zip Code D-14 (rev. 7/99)