Workers’ Compensation Employees Earning Report DWC Form #19

The purpose of this form is to identify what the employee earned.

SECTION II – Notice to Employee

Identify when you began and stopped receiving/claiming benefits. Identify if you received any other compensation during the time you were receiving or claiming benefits. There is an option to attach documentation of your reported earnings.

SECTION III – Reported Earnings

In this section you are asked to identify earnings of any kind you have received, including from individual people. Then list each person or business from which you have received earnings. For example, if earnings were received from a friend for babysitting or any other simple tasks of any kind, the friend’s information needs to be outlined here.

SECTION IV – Self Employment

In this section, identify if you were self-employed at any point during the time period that you reported in section II. If so, state what exactly you were doing for self-employment or the services which you rendered, along with dates you performed services and how much you were compensated for such services. You must disclose the benefits you received from your self-employment.

SECTION V – Social Security Benefits

Identify if you received Social Security Benefits during the time period you reported in section II. If so, report how much you received on a monthly basis, how much of it is categorized as disability benefit, and how much you received for dependents.

SECTION VI – Other Benefits

Identify any source of income or earnings you have received that you have not previously mentioned on this form from any source whatsoever. After identifying the source, state how much and when you received the benefits.