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[]
["State of New Hampshire "]
["DEPARTMENT OF LABOR"]
["CONCORD, NH  03301"]
[]
["SUPPLEMENTAL WAGE SCHEDULE"]
[]
["TO BE COMPLETED ONLY WHEN INDEMNITY RATE IS BASED ON AFTER-TAX EARNINGS AS DEFINED BY RSA 281-A:2, 1-a."]
[]
[]
["Name: ",{"$nulls":5},"Date of Injury:"]
[]
["TOTAL NUMBER OF DEPENDENTS (INCLUDES EMPLOYEE) "]
[]
["FILING STATUS (MARRIED OR SINGLE)       ",{"$nulls":3},"Drop Down Option"]
[]
["LIST NAMES AND AGES OF ALL DEPENDENTS:"]
{"$rows_empty":11}
["1. Average Weekly Wage                                                                                                                    "]
[]
["2. Amount of Federal Withholding Tax to be Deducted using Average Weekly Wage "]
["                                                                                                                   "]
["3. FICA rate factor                                                                                                                   ",{"$nulls":5},"Drop Down Option"]
[]
["4. Multiply amount from Line 1 by Line 3 ",{"$nulls":7},{"$f":"SUM(I29*I33)","v":{"v":0,"d":"$0.00"}}]
[]
["5. Total Deductions (Add Lines 2 and 4)                                                                                             ",{"$nulls":7},{"$f":"SUM(I31+I35)","v":{"v":0,"d":"$0.00"}}]
[]
["6. AFTER-TAX EARNINGS INDEMNITY RATE (Subtract amount in Line 5 from amount in Line 1)  ",{"$nulls":7},{"$f":"SUM(I29-I37)","v":{"v":0,"d":"$0.00"}}]
["                                                                     "]
["7. If Line 1 is below the minimum compensation rate, multiply Line 6 by 90%.                                                                                                                 ",{"$nulls":7},{"$f":"IF(I29 < 307.5,I39 * 0.9,0)","v":{"v":0,"d":"$0.00"}}]
[]
[]
[]
["Signature – Employee                                                              ",{"$nulls":4},"Signature – Adjuster"]
[]
[]
["Date     ",{"$nulls":4},"Date     "]

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