Form 25T PDF Details

If you are an employee of a company, there is a Form 25T that you need to fill out in order to receive your wages. This form is issued by the IRS and it will show all of the taxable wages that you have earned during the year. It's important to file this form so that you can ensure that you are paying the right amount of taxes on your income. There are some specific steps that you need to take in order to fill out the form correctly, so make sure to read through the instructions carefully. By taking advantage of online resources, such as the IRS website, you can make sure that everything is done properly and avoid any potential penalties.

QuestionAnswer
Form NameForm 25T
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesform 25t nc industrial commission, nc form 25t, form 25t, nc industrial commission form

Form Preview Example

NORTH CAROLINA INDUSTRIAL COMMISSION

IC File #

ITEMIZED STATEMENT OF CHARGES FOR TRAVEL

Emp. Code #

Carrier Code #

Carrier File #

The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act

Employer FEIN

Employee’s Name

Address

CityState Zip

(

)

-

(

)

-

Home Telephone

 

Work Telephone

 

 

 

(

)

-

Employer's Name

Telephone Number

 

 

 

 

Employer’s Address

City

State

Zip

 

 

 

 

Insurance Carrier

 

 

 

 

 

 

 

Carrier's Address

City

State

Zip

(

)

-

(

)

-

Carrier's Telephone Number

 

Fax Number

Employees are entitled to reimbursement of $0.58 per mile for travel for medical treatment, provided they travel 20 miles or more roundtrip, starting January 1, 2019. Special consideration will be given to employees who are totally disabled. No reimbursement is allowed for trips to purchase medications or supplies unless medically necessary. These items must be purchased on visits to medical providers (G.S. § 97-25).

 

 

 

 

 

 

 

TOTAL MILES

DATE

 

NAME OF MEDICAL PROVIDER

 

CITY

ROUNDTRIP

/

/

 

 

 

 

 

 

/

/

 

 

 

 

 

 

/

/

 

 

 

 

 

 

/

/

 

 

 

 

 

 

/

/

 

 

 

 

 

 

 

 

If overnight

 

Total motel expense (actual, up to $71.20 per

 

Total Miles:

 

 

 

 

 

 

 

 

 

stay is

 

day in-state or $84.10 per day out-of-state):

 

 

 

 

 

necessary, the

 

 

 

 

 

OTHER

following items

 

Total meal expense ($8.40 Breakfast, $11.00 Lunch,

 

X [mileage rate]*

 

will be

 

and $18.90 in-state or $21.60 out-of-state Dinner):

 

 

 

EXPENSES

 

 

 

 

approved as

 

 

 

Other expenses:

 

 

 

 

 

 

 

 

 

submitted.

 

Total parking & cab expense (actual charge):

 

 

 

 

 

 

 

 

 

 

(Receipts must

 

 

 

 

 

 

 

 

 

 

 

 

 

be furnished for

 

Total for other expenses:

 

Total all expenses:

 

 

 

carrier’s file.)

 

 

 

 

 

 

 

 

 

 

 

*Prior mileage rates are as follows: (a) $0.545 for 2018; (b) $0.535 for 2017; (c) $0.54 for 2016; (d) $0.575 for 2015; (e) $0.56 for 2014

I hereby certify that I have incurred all expenses listed above as a result of my workers' compensation injury.

Employee signature

 

Carrier’s approval

Employee:

 

Employer or Carrier/Administrator:

Mail your bill in duplicate promptly to employer and/or

 

Travel may be reimbursed directly to the employee. It is

insurance carrier

 

not necessary to submit bills to the Commission for

 

 

approval. Pay and retain copy in carrier's file.

 

NOTICE TO INJURED EMPLOYEE:

 

THIS FORM SHOULD BE RETURNED TO THE CARRIER

FORM 25T

AT THE ADDRESS ABOVE FOR PAYMENT.

01/2019

 

PAGE 1 OF 1

FORM 25T

FOR ASSISTANCE, CALL:

N.C. INDUSTRIAL COMMISSION

MAIN TELEPHONE: (919) 807-2500

HELPLINE: (800) 688-8349

How to Edit Form 25T Online for Free

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1. You have to fill out the north carolina industrial commission form accurately, therefore take care while filling out the segments that contain these fields:

north carolina industrial commission form 25t writing process described (stage 1)

2. Now that the previous section is complete, you're ready to add the needed specifics in DATE, NAME OF MEDICAL PROVIDER, CITY, OTHER, EXPENSES, If overnight, stay is, necessary the following items, will be, approved as submitted, Receipts must be furnished for, Total motel expense actual up to, Total meal expense Breakfast, TOTAL MILES ROUNDTRIP, and Total Miles so that you can progress to the 3rd stage.

The way to complete north carolina industrial commission form 25t portion 2

It's easy to make an error while completing the Total Miles, for that reason be sure you look again before you send it in.

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