Form CA-2231 Claim for Reimbursement Assisted Reemployment

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U.S. Department of Labor

Claim For Reimbursement
Assisted Reemployment

Employment Standards Administration
Office of Workers' Compensation Programs

Instructions: Complete items 1 through 16 and send to the Division of Rehabilitation. If item 5 does not apply to you leave it blank.
No further monies may be paid out under this program unless this report is completed and filed, as required by terms of the
Cooperative Agreement entered into by you and OWCP. (P.L. 106.554)
1. Employer's Name

2. Phone Number

3. Employer's Complete Mailing Address:

4. Employer's Tax I.D. No.

5. Employer (Federal)
Appropriations Code

Street or Post Office Box Number

City

OMB No. 1215-0178
Expires: 06-30-2007

ZIP Code

State

7. OWCP File Number
6. Claimant's Name
Last

M.I

First

8. Social Security Number

10. Reporting Quarter
9. Date Employment Began
Month

11. Dates and Hours Worked

Day

12. Pay Rate Per Hour

Year

13. Total Amount Earned

14. Amount of Reimbursement Claimed

I certify that the information provided on this form is true and correct to the best of my knowledge.
16. Date

15. Supervisor's Signature

For OWCP Use Only Below This Space:
Percentage Allowed:

%

Total Amount This Payment $

Authorized by:

Date:

Public Burden Statement

We estimate that it will take an average of 30 minutes per response to complete this information collection, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. If you have any comments regarding this burden estimate or any other aspect of the survey, including
suggestions for reducing this burden, send them to the U.S. Department of Labor, Office of Workers' Compensation Programs, Room
S3229, 200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED SURVEY TO THE ABOVE
OFFICE
Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
Form CA-2231
June 2004