Ohio Form Bwc 1217 PDF Details

Ohio Form BWc 1217 is an important document for employers in the state. The form must be completed and filed to report wages paid to employees, both exempt and non-exempt from withholding taxes. The form must be filed by the last day of the month following the end of the taxable quarter. Filing late can result in penalties and interest charges. The information on Ohio Form BWc 1217 is used to determine whether or not an employer is required to withhold federal income tax from employee wages. It's important to make sure all information is accurate so that proper taxes are withheld.

You will find info about the type of form you wish to prepare in the table. It will show you the span of time you will require to fill out ohio form bwc 1217, what parts you need to fill in and a few other specific details.

Form NameOhio Form Bwc 1217
Form Length3 pages
Fillable fields250
Avg. time to fill out25 min 24 sec
Other namesohio bwc wage statement, ohio wage statement, ohio bwc statement, ohio bwc

Form Preview Example



Wage Statement




Injured worker name

Date of injury

Claim number




Phone number

Cell number





Employer name

Phone number





Email address






Instructions for the employer

Complete and sign this wage statement. It is not necessary for you to complete the affidavit, unless you are also the injured worker.

Report gross earnings. Gross wages include all earnings for the injured worker prior to any deductions such as for taxes, insurance or employee contributions to retirement programs. Include earnings amounts from paid holidays, vacation, personal or sick leave used (but not leave time paid but not used). Earnings are reported in the periods they are earned, not when they are paid. Some earnings such as bonuses and commissions need to be prorated.

Instructions for the injured worker

Failure to file wage statements may delay or adversely affect rates of compensation.

If you are self-employed or unemployed, complete and sign this report, including the affidavit. The affidavit may be sworn to without cost before a deputy in a BWC local customer service office.

If anyone other than the employer of record in this claim employed you during the year prior to the date of injury, you must obtain this information from those employers. If your other employer completes this form, it is not necessary for that employer to complete the affidavit.

If detailed earnings from your employer(s) are not available, you can provide other documentation such as W-2s or Social Security reports. If you submit a 1099, information reported to the IRS or a sworn statement regarding expenses related to that income must accompany it. BWC will assume earnings submitted on a W-2, Social Security report or 1099 were earned over the entire year unless specifically noted.

This form was completed by:

Employer of record

Injured worker

Other employer

You must provide this information, even if you are providing weekly earnings on an attached report.

Date of hire

Provide information based on pay period begin and end dates, not payment dates.

For the full pay period that ended prior to the date of injury:

Pay period begin date

Pay period end date

During the last seven days of that pay period:

Regular earnings

Overtime earnings

Total gross earnings

If employed less than one full pay period prior to the date of injury, provide the following information:

Number of hours scheduled the week of the injury

Hourly rate

If the injured worker received any bonuses, allowances or other payment, please describe the nature of the payment and time period over which it was earned below. You may also provide other information for us to consider in the calculation of FWW and/or AWW such as periods of unemployment in the space below.

Injured worker name

Claim number

BWC-1217 (Rev. 7/30/2012) WAGES formerly known as C-94A

Wage Statement

You may submit earnings by providing a report that includes the required information as described below or by completing this worksheet.

Report the pay period dates, not the date payment was made.

Report any periods the injured worker did not work. If payment was made during those periods, report the amount and description of payment the injured worker received.

If the employee received an allowance for meals, lodging, tips, etc in addition to wages, report as other earnings with a description of the earnings. It is not necessary to report reimbursements made to the injured for travel, uniforms, etc. BWC does not consider reimbursements earnings for calculations of wages.

If the injured worker received a bonus during the reporting period, report as other earnings with a description of the earnings which includes the period of time over which it was earned.

Report earnings beginning with the full pay period that ended prior to the date of injury. When setting the

periods to report, you may adjust the reporting periods backward to line up the reporting time frames with the employer’s pay cycle. Do not report wages earned on or after the date of injury.

Payment is made (check one)


Every two weeks

Twice a month



Use the worksheet below, or attach other documentation to provide earnings information for the 52 weeks prior to the date of injury, beginning with the full pay period prior to the date of injury.

Pay period end date

Gross amount earned

Other earnings

Description of exceptions






























BWC-1217 (Rev. 7/30/2012)

WAGES formerly known as C-94A

Wage Statement
























I certify the information provided is correct to the best of my knowledge. I am aware that any person who knowingly makes a false statement, misrepresentation, concealment of fact, or any other act of fraud to obtain payment as provided by the BWC or who knowingly accepts payment to which that person is not entitled, is subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine, imprisonment or both.



Employer name and title


Employer signature and title


State of Ohio, County of __________________________________ Social Security number: __________________________________

being first duly sworn, says that the entire earnings from ___________________ to ___________________ ; as listed above is correct.

If unable to write, mark must be witnessed by two persons.

Sworn to before me, and subscribed in my presence

Signature of applicant

day of








Official title

BWC-1217 (Rev. 7/30/2012) WAGES formerly known as C-94A

How to Edit Ohio Form Bwc 1217 Online for Free

It is possible to create the bureau compensation wage statement online form with our PDF editor. The following actions may help you easily prepare your document.

Step 1: On the web page, hit the orange "Get form now" button.

Step 2: You'll find each of the actions that it's possible to undertake on your document once you have accessed the bureau compensation wage statement online editing page.

If you want to fill in the bureau compensation wage statement online PDF, enter the details for all of the parts:

filling in bwc forms c 23 ohio bwc step 1

Put down the data in the This, form, was, completed, by Employer, of, record Injured, worker Other, employer Pay, period, enddate Overtime, earnings Total, gross, earnings and Hourly, rate field.

stage 2 to completing bwc forms c 23 ohio bwc

The software will ask you to put down some key info to easily fill in the segment Injured, worker, name Claim, number and B, WC, Rev, WAGES, formerly, known, as, CA

Entering details in bwc forms c 23 ohio bwc stage 3

The area Payment, is, made, check, one Weekly, Every, two, weeks Twice, a, month Monthly, Other, Description, of, exceptions Pay, period, enddate Gross, amount, earned and Other, earnings will be for you to add both parties, ' rights and responsibilities.

stage 4 to finishing bwc forms c 23 ohio bwc

Review the sections B, WC, Rev, WAGES, formerly, known, as, CA and next complete them.

part 5 to finishing bwc forms c 23 ohio bwc

Step 3: After you pick the Done button, your finished file is easily exportable to any kind of of your devices. Alternatively, you may deliver it by means of mail.

Step 4: To avoid any sort of headaches in the future, be sure to create a minimum of a couple of copies of your file.

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .