Are you a U.S. Citizen or resident alien? If so, you're required to file Form 25R each year with your federal income tax return. This form is used to report worldwide income and to claim any applicable tax treaty benefits. Read on for more information about what this form entails, and be sure to contact an accountant if you have any questions. Did you know that as a U.S. citizen or resident alien, you're required to file Form 25R each year with your federal income tax return? This form is used to report worldwide income and to claim any applicable tax treaty benefits. In this article, we'll cover what information is included on Form 25R, as well as some of the reasons why you might need to file it. Be sure to contact an accountant if you have any questions about whether or not you need to file this form.
| Question | Answer |
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| Form Name | Form 25R |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | 25r form, 25 r, 25 r form, form 25r pdf north carolina |
NORTH CAROLINA INDUSTRIAL COMMISSIONIC File #
EVALUATION FOR PERMANENT IMPAIRMENT |
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Carrier Code # |
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Carrier File # |
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act |
Employer FEIN |
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Employee’s Name
Address
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Social Security Number |
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Date of Birth |
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Date of Injury:
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Employer's Name |
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Employer’s Address |
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Insurance Carrier |
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Carrier's Address |
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Carrier's Telephone Number |
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EMPLOYEE'S
MEMBER |
% OF IMPAIRMENT |
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(IF AMPUTATION, DESCRIBE ON REVERSE.) |
1)Thumb
2)Index Finger
3)Middle Finger
4)Ring Finger
5)Little Finger
6)Great Toe
7)Toes (other than great toe)
8)Hand
9)Arm
10)Foot
11)Leg
12)Back
In regard to this rated body part:
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Is employee at maximum medical improvement? |
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Was employee released with restrictions? |
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Physician Signature
Printed Name
Fed. Tax ID Number
Date
Address
TEETH: Age of employee:
List all crowns by number :
List all extractions by number :
Has dental work been completed? Yes No
VISION: List vision reading without the use of a corrective lens.
Distance: |
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Near: |
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HEARING: Scale used: |
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Percentage of loss: Right ear |
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PLEASE ATTACH AUDIOGRAMS AND CALCULATIONS OF HEARING LOSS |
Left ear |
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OTHER: Permanent injury to or impairment of any other organ or part of body (identify) : |
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Disfigurement: Yes No |
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Location: face head |
body |
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FORM 25R |
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NCIC - CLAIMS SECTION |
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FORM |
25R |
4335 MAIL SERVICE CENTER |
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8/1/08 |
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RALEIGH, NORTH CAROLINA |
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PAGE 1 OF 2 |
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MAIN TELEPHONE: (919) |
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HELPLINE: (800)
WEBSITE: HTTP://WWW.IC.NC.GOV/
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Rule 405 |
Comments: |
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Computation of Compensation for Amputations |
(1)Amputation of any portion of the bone of a distal phalange of a finger or toe at or distal to the visible base of the nail will be considered as equivalent to the loss of
(2)Amputation of any portion of the bone of the distal phalange of a finger or toe proximal to the visible base of the nail will be considered as equivalent to the loss of
(3)Amputation through the forearm at a point so distal to the elbow as to permit satisfactory use of a prosthetic appliance with retention of full natural elbow function shall be considered amputation of the hand. Otherwise, it shall be considered amputation of the arm.
(4)Amputation through the lower leg at a point so distal to the knee as to permit satisfactory use of a prosthetic appliance with retention of full natural knee function shall be considered amputation of the foot. Otherwise, it shall be considered amputation of the leg.
A copy of this form must be provided to the employee or the employee’s attorney of record if any.
The original should be mailed to the Industrial Commission at the address below.
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FORM 25R |
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NCIC - CLAIMS SECTION |
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FORM 25R |
4335 MAIL SERVICE CENTER |
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8/1/08 |
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RALEIGH, NORTH CAROLINA |
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PAGE 2 OF 2 |
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MAIN TELEPHONE: (919) |
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HELPLINE: (800) |
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WEBSITE: HTTP://WWW.IC.NC.GOV/ |