Statutory Quarterly Paid Claims Report
For the period: mm/dd/yyyy through mm/dd/yyyy

Claim Status Active:
Claim Status Closed:

SSN:
Benefits Paid Each Quarter:
 Total Paid this Period:
 Total Paid to Date:
Claim is active on report run date and was paid benefits during report period.
Claim is closed on report run date and was paid benefits during report period.

Claimant's Social Security Number.
The sum of benefits (before taxes) paid during the specified quarter.
The sum of benefits paid for all four quarters during report period.
The sum of all benefits paid to the claimant. Includes any benefits paid prior
to report periods.

Contract: 123456 - Admin Unit: PORT - Status: CLOSED
Claimant
SSN
Claim Number		 Duration (Days) Benefits Paid
Qtr. 1		 Benefits Paid
Qtr. 2		 Benefits Paid
Qtr. 3		 Benefits Paid
Qtr. 4		 Total
This Period		 Total
to Date		  
JIM PETERS
xxx-00-1111
00001111		 53 $0.00 $0.00 $594.05 $0.00 $594.05 $594.05  
LISA DAVIS
xxx-00-2222
00002222		 21 $982.74 $0.00 $0.00 $0.00 $982.74 $982.74  
FRANK JONES
xxx-00-3333
00003333		 62 $0.00 $0.00 $98.90 $1,127.47 $1,226.37 $1,226.37  
PATRICIA DANIELSON
xxx-00-4444
00004444		 159 $6,359.69 $2,392.77 $0.00 $0.00 $8,752.46 $8,752.46  
WILMA SMITH
xxx-00-5555
00005555		 119 $17,535.16 $0.00 $0.00 $0.00 $17,535.16 $17,535.16  
Totals for Admin Unit: PORT Q1
$2,392.77		 Q2
$24,877.59		 Q3
$1,127.47		 Q4
$692.95		 Total Paid This Period
$29,090.78		 Total Paid To Date
$29,090.78