Ohio Form Bwc 1217 – Fill Out and Use This PDF

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.

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:

During the last seven days of that pay period:

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

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.

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

Wage Statement

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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

X

Employer signature and title

Affidavit

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

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

Official title

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