Form C 30 PDF Details

If you are a business owner, you likely know about Form C-30. This is the form that businesses in California must submit to the Franchise Tax Board (FTB). The purpose of this form is to report certain information about your business, including its income and expenses. While submitting this form may seem like a complicated task, our team at _____ can help you through the process. In this blog post, we will provide an overview of what you need to know about Form C-30. We will also outline some tips for completing the form accurately and efficiently. So if you are ready to learn more, keep reading!

QuestionAnswer
Form NameForm C 30
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesbwcc30form, form c 30, c30a form tennessee, form c30

Form Preview Example

FORM C-30

TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT

Division of Workers' Compensation

220 French Landing Dr.

Nashville, Tennessee 37243-1002

ATTENDING PHYSICIAN'S REPORT

It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers' compensation transaction for the purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits.

 

1.

Name of Injured Person:

 

 

 

 

 

 

 

 

PATIENT

SSN:

 

 

Age:

 

Sex:

 

2.

Address:

 

 

City:

 

State:

 

Zip:

3.

Employer Name:

 

 

 

 

 

 

 

 

Address:

 

 

City:

 

State:

 

Zip:

 

 

 

 

 

ACCIDENT

4.

Date of Accident:

Hour:

AM/PM

 

Date of Disability:

5.

State in patient’s own words where and how accident occurred:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Give accurate description of nature and extent of injury and state your objective findings:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

Is accident referred to above only cause of patient’s condition?

 

 

 

INJURY

 

If not, state contributing causes:

 

 

 

 

 

 

 

 

8.

Is patient suffering from any disease of the heart, lungs, brain, kidneys, blood, vascular system or any

other disabling condition not due to this accident?

 

 

 

 

 

 

Give particulars:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Has patient any physical impairment due to previous accident or disease?

 

 

 

 

Give particulars:

 

 

 

 

 

 

 

 

 

10.

Has normal recovery been delayed for any reason?

 

 

 

 

Give particulars:

 

 

 

 

 

 

 

 

 

11.

Who engaged your services?

 

 

 

 

 

 

 

 

 

12.

Date of your first treatment:

 

 

 

 

 

 

 

 

TREATMENT

13.

Describe treatment given by you:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14.

Was patient treated by anyone else?

 

When?

 

 

 

15.

Was patient hospitalized?

 

 

 

Name of hospital:

 

 

 

Address of hospital:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16.

Date of admission to hospital:

 

 

 

Date of discharge:

 

 

17.

Is further treatment needed?

 

 

 

For how long?

 

 

 

DISABILITY

18.

Will the injury result in:

 

 

 

 

 

 

 

 

(a)

Permanent Defect?

 

If so, what?

 

 

 

(b) Facial or head disfigurement?

 

 

 

 

 

 

 

 

19.

Date able to return to work:

 

 

 

 

 

 

 

 

20. Date able to return to work light duty:

 

 

 

 

 

 

 

21.

If death ensued, give date:

 

 

 

 

 

 

 

 

 

Remarks: (Give any information of value not listed above)

 

 

 

 

 

 

 

 

 

 

This report must be signed personally by physician.

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of report:

 

 

 

Signed

 

 

 

 

Address:

 

 

 

Telephone:

 

 

 

LB-0022 (REV. 12/07)

RDA 10183

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This PDF form will require particular information to be filled in, hence you must take whatever time to provide what's asked:

1. The form c30 tennessee needs specific details to be entered. Make certain the following fields are completed:

Completing part 1 of form c30

2. After this part is filled out, go on to type in the applicable details in these: Give accurate description of, Date of discharge For how long, When Name of hospital, If so what, Date of report Address, Signed Telephone, T N E M T A E R T, Y T I L I B A S I D, and LB REV RDA.

form c30 writing process outlined (portion 2)

It is possible to make a mistake while filling in your Date of report Address, therefore you'll want to reread it before you decide to send it in.

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