Average Weekly Wage Computation Schedule {127}

DIA USE ONLY Make any comments on the reverse side of this form or on a separate sheet. Form 127 Revised 7/2019 Reproduce as needed. AVERAGE WEEKLY WAGE COMPUTATION SCHEDULE Indicate only those wages earned by the injured worker during the 52 week period immediately preceding the accident . If the injured employee has worked for less than 52 weeks, report wages from the time worked and, for the remaining weeks on this schedule, substitute wages of a fellow employee in the same class of employment who has worked for one year or more . 16. Date Signed (mm/dd/yyyy): The Commonwealth of Massachusetts Department of Industrial Accidents Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111 - 1750 Info. Line (800) 323 - 3249 Inside Mass. / (857) 321 - 7470 Outside Mass. www.mass.gov/dia FORM 127 Print or Type 8. Date of Disability (mm/dd/yyyy): 7. Date of Injury (mm/dd/yyyy): 5. # of dependent children: 6. # of other dependents: 3. DIA Board # (if known): 9. Date of Employment (mm/dd/yyyy): 10. Has employee been certified by U.S. Veterans Administration for any type of disability? Yes No 11. Week No. Year: Week Ending Month Day Year: Week Ending Month Day Gross Amount Before Taxes Gross Amount Before Taxes 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 Week No. Year: Week Ending Month Day Gross Amount Before Taxes 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 Week No. Total: 12. Was room furnished to the employee? Yes No 13. If tips or other benefits were earned, describe and state value per week: THIS IS A TRUE COPY OF THE PAYROLL RECORD OF THE ABOVE NAMED EMPLOYEE OR FELLOW EMPLOYEE IN THE SAME CLASS OF EMPLOYEMENT 14. Name of Fellow Employee (if applicable): 15. Employer/Preparer Signature: American LegalNet, Inc. www.FormsWorkFlow.com Comments: American LegalNet, Inc. www.FormsWorkFlow.com