Form ca-1122 Statement of Recovery

Date: Telephone number:

File Number:

Date of Injury:

Employee:

OMB No. 1215-0200

Expiration Date: 6/30/2009

Dear

Our records show that you have presented a claim or instituted a suit for damages against the third-party apparently responsible for your injury without retaining the services of an attorney.

The Federal Employees' Compensation Act provides that the United States must be reimbursed out of any third-party recovery for any disbursements made to you or on your behalf by the United States. Therefore, you should include disbursements as damages in your claim. A statement of disbursements is attached, if any have been made. If you received additional treatment or compensation, contact the Office of Workers’ Compensation Programs (OWCP) for a current statement of disbursements before settling or concluding your claim.

You must notify this office of any recovery you obtain. Completing and submitting the enclosed EN-1122 will serve as your notice of a recovery obtained without the services of an attorney. It will also enable you to determine the amount of any refund you must pay.

WARNING

A FALSE OR EVASIVE ENTRY ON FORM EN-1122, OR THE OMISSION OF AN ENTRY ON THE FORM, MAY SUBJECT YOU TO CIVIL LIABILITY. A FRAUDULENT ENTRY MAY RESULT IN CRIMINAL PROSECUTION. ALL ENTRIES ON FORM EN-1122 ARE SUBJECT TO INVESTIGATION FOR VERIFICATION.

Following your submission of the EN-1122, you will be advised further of your compensation status.

If you should retain the services of an attorney to assist you in your third-party claim, please advise this office immediately and provide the attorney’s name and complete address.

Sincerely,

Enclosure(s): EN-1122

PRIVACY ACT STATEMENT

The following statement is made in accordance with the Privacy Act of 1974 (5. U.S. C. 522a). The authority for requesting the information is the Federal Employees’ Compensation Act (FECA) (5 U. S. C. 8101 et seq). Information collected will be handled and stored in compliance with the Freedom of Information Act, the Privacy Act of 1974, as amended (5 U.S.C. 552a). The information will be used to determine the amount of refund due to the United States out of the proceeds of a third party action. Failure to furnish the requested information will result in a delay in processing the third party recovery.

PUBLIC BURDEN STATEMENT

We estimate that it will take an average of 15 minutes to respond to this collection of information, which includes time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. A respondent’s obligation to respond is required in accordance with 5 U.S.C. 8131-8132 of the FECA to obtain or retain benefits. If you have any comments regarding this estimate or any other aspect of this collection of information, including suggestions for reducing this burden, send them to the U.S. Department of Labor, OWCP, Room S-S3229, 200 Constitution Avenue, NW, Washington, DC 20210 and reference the OMB control number. DO NOT SEND THE COMPLETED FORM TO THIS ADDRESS. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of the information unless such collection displays a valid OMB control number.

File Number: Employee:

SHORT FORM STATEMENT OF RECOVERY

(See following page for instructions)

Date of judgment or release: _______________________________

1. Amount of Gross Recovery $ _____________________

2. Amount for Property Damage, if any _____________________

3. Balance (Line 1 minus Line 2) _____________________

4. Amount for Loss of Consortium, if any _____________________

(Line 4 is _____% of Line 3)

5. Balance (Line 3 minus Line 4) _____________________

6. Enter 20% of Line 5 _____________________

7. Balance (Line 5 minus Line 6) _____________________

8. Enter OWCP Disbursements of $ ____________

or amount on Line 7 above, whichever is less

* * * REFUND THIS AMOUNT TO OWCP * * *

______________________

9. Surplus (Line 7 minus Line 8) _____________________

* * *CREDIT AGAINST FUTURE BENEFITS * * *

CERTIFICATION

I certify that each and every statement made above is true to the best of my knowledge. I understand that any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud to obtain compensation provided by the Federal Employees’ Compensation Act, or who knowingly accepts compensation to which that person is not entitled, is subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine and/or imprisonment.

__________________________________________________________

Signature Date

__________________________________________________________

(For use by OWCP only)

Approved: __________________________ Date ___________

INSTRUCTIONS FOR FORM EN-1122

*Distribution of the proceeds from the third party recovery must be made in accordance with 5 U.S.C. section 8132.*

PROPERTY DAMAGE (Line 2) A reasonable amount for clothing or other personal belongings that are damaged or destroyed in an accident may be deducted. These amounts must be itemized. If an automobile or other vehicle is damaged or destroyed, furnish the year, make and model, and the Blue Book value of the vehicle. A copy of the repair bill will suffice if the vehicle was not totally destroyed.

LOSS OF CONSORTIUM (LINE 4) Amounts received for loss of consortium are also deducted from the gross recovery, if approved by OWCP. OWCP will consider an allocation of up to 40% (up to 25% for a spouse and up to 5% per child, to a maximum of 15% for all children) of the amount on Line 3 to loss of consortium. The approved allocation must be expressed as a percentage of the amount on Line 3 in the space provided.

20% GUARANTEE (Line 6) This amount is retained by you and is not subject to any deductions.

OWCP DISBURSEMENTS (LINE 8) All amounts paid by OWCP (compensation and medical benefits, but not COP) less the gross amount of any prior refunds made (from Line 7 on any earlier EN-1122) are to be entered in the space provided. If the OWCP disbursements are larger than the amount on Line 7, then enter the amount on Line 7 in the blank for Line 8 in the column on the right. This is the amount to be refunded to OWCP.

SURPLUS (Line 9) The surplus is retained by you and is the amount against which OWCP will credit future compensation payable on account of the same injury. Because you will not be entitled to any further payments from OWCP until you are eligible for additional compensation in an amount greater than the surplus, you should submit all medical bills you have paid for the injury to OWCP, regardless of when you paid them. You will not be reimbursed for these payments, but the amount you paid will be used to reduce the amount of the surplus.

The refund check for the amount shown on line 8 should be made payable to "U.S. Department of Labor, OWCP" and sent to the following address, unless otherwise instructed:

U.S. DEPARTMENT OF LABOR

CA-1122 Page 1

August 2002