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…Duties: _________________________ Hours lost: ____________________ From:_________________ To: __________________ Month/Day/Year Month/Day/Year Net income lost: $____________________ (Minus sick leave) Employer’s representative: _________________________ Position: __________________ Employer’s phone number: _________________________ If the employer is…

…(date) ______________________ To (date): ____________________________ Net income lost: $___________________ (Minus sick leave) Employer’s representative (print) _______________________________ Phone: _____________________________ Return to : Crime Victim Compensation 201 W. Colfax, Dep. 801 Denver,…