Form LS-426 Request for Earnings Information

Employment
Employment Standards
Standards Administration
Administration

U.S. Department of Labor

Office of
of Workers'
Workers' Compensation
Compensation Programs
Programs
Office
Division of
of Longshore
Longshore and
and Harbor
Harbor Workers'
Workers' Compensation
Compensation
Division

OWCP File No:
Claimant:
Injury Date:

OMB No. 1215-0112
Expires: 06/30/2009

Dear Mr/Ms ___________________________________:
Our records indicate that you are or were receiving compensation at the rate of $____________
per week based on earnings reported by your employer.
If you feel that you are entitled to a higher compensation rate, you may submit a record of your
earnings from all types of employment for the 52 weeks prior to your injury. You may also
provide reasons why your benefit rate should not be based on earnings in the year prior to your
injury alone. Please use the back of this form for this purpose. Please submit documentation
of earnings such as W2s, wage slips or statement from your employer.
Please send the requested information to the office address shown above within 30 days. We will
review the earnings information you provide to determine whether the compensation rate is
accurate.
Sincerely,

Enclosure
PRIVACY ACT OF 1974 NOTICE
In accordance with the Privacy Act of 1974, as amended, (5 U.S.C. 522a ), you are hereby notified that: (1) The Longshore a nd Harbor
Workers' Compensation Act (LHWCA), as amended and extended (33 U.S .C. 901 et seq.), is administered by the Office of Workers'
Compensation Programs of the U.S. Department of Labor which receives and maintains information on claimants and their immediate families.
(2) Information which the Office has will be used to determine eligibility for the amount of benefi ts under the LH WCA. (3) Information may be
given to the employer which employed the claimant at the time of injury, or to the insurance carrier or other entit y which secured the employer's compensation liability. (4) Information may be given to the physicians and other medical service providers for use in providing treatment or
medical/vocational rehabilitation, making evaluations and for other purposes relating to the medical management of the claim. (5) Information
may be given to the Department of Labor's Office of Administrative Law Judges (OALJ), or other person, board or organization, which is authorized or required to render decisions with respect to the claim or other matter arising in connection with the claim. (6) Information may be given to
Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the LHWCA, to determine whether benefits are being and have been paid properly, and, where appropriate, to pursue salary/administrative offset and debt collection actions
required or permitted by law. (7) Failure to disclose all requested information may delay the processing of the claim, the payment of benefits, or
may result in an unfavorable decision or reduced level of benefits.
Note: The notice applies to all forms requesting information that you might receive f rom the Office in connection with the proc essing and/or
adjudication of the claim you filed under the LHWCA and related statutes.
This form letter is used to request earnings information. The information will be used to determine the correct compensation rate. Submission of
the report is required to obtain payment at the correct rate (33 USC 910). Include your address, ZIP code, and file number on all correspondence.
Form LS-426
Rev. November 2008

2

OWCP File No: ________________
Claimant:
Note: Earnings for several months may be grouped if desired.

20___

Name of Employer

Occupation

Amount

Earned

Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
20____
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec

Signature
Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such
collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 15
minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain
or retain benefits. The authority for requesting this information is 33 USC 910. Send comments regarding the burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Division
of Longshore and Harbor Workers' Compensation, Room C-4315, Washington, D.C. 20210, and reference the OMB Control Number
(1215-0112). Note: Please do not return the completed LS-426 to this address.