Form ca-1108 Statement of Recovery

Date: Telephone number:

File Number:

Date of Injury:

Employee:

OMB No. 1215-0200

Expiration Date: 6/30/2009

Dear

We have been advised that you have been retained to represent the above-named employee with respect to the third-party damage claim arising from the above-referenced injury. You will also find a statement showing the disbursements made to date in this case, if any have been made. We have also enclosed a Form EN-1108, Long Form Statement of Recovery, for you to fill out and submit to the address below. If requested, we will furnish you an updated statement of disbursements and/or copies of any additional medical reports.

If you have any questions concerning the third-party aspects of this case or about the obligations and responsibilities imposed pursuant to 5 U.S.C. sections 8131 and 8132 and the applicable regulations (20 C.F.R. sections 10.705 through 10.719), please contact the Office of the Solicitor of Labor’s Division of Federal Employees' and Energy Workers' Compensation. That particular office, which is responsible for handling the third-party aspects of this case, will be in contact with you. The telephone number for that office is 202-693-5320.

The address of the Office of the Solicitor of Labor (SOL) is:

U. S. Department of Labor

Office of the Solicitor

200 Constitution Avenue N.W. S4325

Washington, DC 20210

When you have completed the enclosed Form EN-1108, sign it and return it to the Office of the Solicitor at the address shown above. Your signature certifies that the statement does or does not represent the final recovery against all defendants. If you have any questions about completing Form EN-1108, call or write to the Office of the Solicitor.

WARNING

A FALSE OR EVASIVE ENTRY ON FORM EN-1108, 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-1108 ARE SUBJECT TO INVESTIGATION FOR VERIFICATION.

Sincerely,

Enclosure: EN-1108

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 (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. In addition to those Department-wide routine uses set forth above in the General Prefatory Statement to this document, disclosure of information from this system of records may be made to the following individuals and entities for the purposes noted when the purpose of the disclosure is both relevant and necessary and is compatible with the purpose for which the information was collected: to any attorney or other representative of a FECA beneficiary for the purpose of assisting in a claim or litigation against a third party or parties potentially liable to pay damages as a result of the FECA beneficiary's FECA-covered injury and for the purpose of administering the provisions of sections 8131-8132 of the FECA. Any such third party, or a representative acting on that third party's behalf, may be

provided information or documents concerning the existence of a record and the amount and nature of compensation paid to or on behalf of the FECA beneficiary for the purpose of assisting in the resolution of the claim or litigation against that party or administering the provisions of sections 8131-8132 of the FECA. DOL/GOVT-1 (Office of Workers' Compensation Programs, Federal Employees' Compensation Act File) 67 F.R. 16827, 4/8/02.

PUBLIC BURDEN STATEMENT

We estimate that it will take an average of 30 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-3229, 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:

LONG FORM STATEMENT OF RECOVERY

(See following pages for instructions)

Amount of Gross Recovery $ ___________________________

Amount for Property Damage, if any ___________________________

Balance (Line 1 minus Line 2) ___________________________

Amount Allocated for Loss of Consortium ___________________________

(Line 4 is _____% of line 3)

Balance (Line 3 minus Line 4) ___________________________

Amount Allocated for Wrongful Death or Survival ___________________________

(circle one) Line 6 is _____% of Line 5.

Balance (Line 5 minus Line 6) ___________________________

Less Attorney’s Fee (Fee is _____% of line 7) ___________________________

Balance ___________________________

Less Court Costs (SEE INSTRUCTIONS FIRST) ___________________________

Balance (adjusted gross recovery) ___________________________

Enter 20% of amount on Line 11 ___________________________

Balance (Line 11 minus Line 12) ___________________________

Enter OWCP Disbursements of $ _______________ ___________________________
or amount on Line 13 above, whichever is less

Government Allowance for Attorney's Fee ___________________________
(retained by claimant)

Balance (Line 14 minus Line 15) ___________________________
* * * REFUND THIS AMOUNT TO OWCP * * *

Surplus (line 13 minus line 14) ___________________________
* * * CREDIT AGAINST FUTURE BENEFITS * * *

CERTIFICATION

I understand that anyone who fraudulently conceals or fails to report information that would have an effect on any benefits, or who makes a false statement or misrepresentation of a material fact in claiming a payment or benefit under the Federal Employees’ Compensation Act may be subject to criminal prosecution, from which a fine and/or imprisonment may result.

I certify that the above statements made on Form EN -1108 do / do not (circle one) represent the final recovery against all defendants, and that they are true, complete and correct to the best of my knowledge and belief. I have placed “Not Applicable (N/A)” or “None” next to those entries that do not apply to this case.

___________________________________ _______________________

Signature Date

___________________________________

Print Name

_____________________________________________________________________________________

(This space for use by Office of the Solicitor only)

Approved: ____________________________ Date: _________________________

INSTRUCTIONS FOR FORM EN-1108

*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 subtracted from the gross recovery, if approved by the SOL. SOL 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 to be reasonable in a non-death case, or a death case where no cause of action for wrongful death is asserted. In a death case with a cause of action for wrongful death, SOL will consider an allocation of up to 25% (up to 15% for a spouse and up to 5% per child, to a maximum of 10% for all children) of the amount on Line 3 to loss of consortium to be reasonable. The allocation must be expressed as a percentage of the amount of Line 3 in the provided space.

WRONGFUL DEATH OR SURVIVAL (LINE 6) Amounts received in death claims for wrongful death or survival actions must be allocated between the two actions, and separate EN-1108s must be filed for each allocation. SOL will consider an allocation to be reasonable if 65% of the amount on Line 5 is allocated to the wrongful death action and the remaining 35% is allocated to the survival action. The allocation forming the basis for this EN-1108 must be expressed as a percentage of Line 5. To complete line 6 for wrongful death actions enter 35% of line 5 and to complete line 6 for survival actions enter 65% of line 5.

ATTORNEY'S FEE (Line 8) A reasonable attorney’s fee, but not more than the fee actually paid, may be deducted from the balance on Line 7. The fee must also be expressed as a percentage of Line 7 in the designated space.

COURT COSTS (Line 10) These consist of such items as filing fees, witness fees, actual costs of collection, or any payments for expert testimony as opposed to payments for medical treatment. COURT COSTS MUST BE ITEMIZED TO BE ALLOWABLE BY SOL. To determine the amount to be listed on Line 10, multiply the court costs allowed by SOL by the percentage shown at Line 4, and subtract this amount from the allowed court costs. Multiply the balance by the percentage shown at Line 6 and enter this amount on Line 10.

20% GUARANTEE (Line 12) This amount is turned over to the claimant and is not subject to any deductions.

OWCP DISBURSEMENTS (LINE 14) Enter all amounts paid by OWCP (for compensation and medical benefits, but not Continuation of Pay), less any amounts listed on Line 14 on any prior Forms EN-1108, in the space provided. If the OWCP disbursements are larger than the amount on Line 13, then enter the amount on Line 13 in the blank for Line 14 in the column on the right. This is the amount to be refunded to OWCP.

GOVERNMENT ALLOWANCE FOR ATTORNEY'S FEE (Line 15) The Government contributes a portion of its refund to the claimant toward payment of the attorney’s fee. This is computed by applying the percentage shown at Line 8 (if SOL considers it reasonable) to the amount listed on Line 14.

REFUND AMOUNT (Line 16) This balance is the amount to be refunded to the Government for OWCP disbursements.

SURPLUS (Line 17) The surplus is retained by the claimant and is the amount against which OWCP will credit future compensation on account of the same injury. Because the claimant will not be entitled to any further payments from OWCP until he or she is eligible for additional compensation in an amount greater than the surplus, all medical bills related to the injury that the claimant pays should be submitted to OWCP, regardless of when payment was made. The claimant will not be reimbursed for these payments, but the amounts paid will be used to reduce the amount of the surplus.

The refund check for the amount shown on line 16 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

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CA-1108 Page 0 August 2002