This government document is issued by Natural Resources - Colorado State Land Board for use in Colorado
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https://www.google.com/url?client=internal-element-cse&cx=005331801672446424340:k3wmy1zqe2a&q=https://cdle.colorado.gov/sites/cdle/files/UIB-5%252C%2520Statement%2520of%2520Wages%2520and%2520Possible%2520Benefits%2520%25284-2016%2529.pdf&sa=U&ved=2ahUKEwi53szP6-mIAxVmgf0HHQgvE_g4FBAWegQIBxAB&usg=AOvVaw23aXcAQPpKDVzq-q8PyxXB