Form LS-276 Application for Security Deposit Determination

Certification of Funeral Expenses
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U.S. Department of Labor
 






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The information provided on this form will be used to determine the amount of funeral expenses that are
payable. Completion of the form is required to obtain payment for services performed (20 CFR §
702.121.) Persons are not required to respond to this collection of information unless it contains a
currently valid OMB control number.
3. Name of deceased
First Name

M.I.

OMB No. 
Expires: 02-28-2011
For Office Use
1. OWCP No.

Last Name
2. Carrier's No.

4. Funeral Director (Name, address, ZIP code)
name:
line 1:
line 2:

city:

country:

state:
Services Performed
(itemize below and enter costs)

5.

$

Comments

(If additional space is required continue on reverse)
Enter name, address, and relationship to deceased.
6. I was informed
name:
that the above
bill would be
city:
line 1:
paid by
line 2:
state:
7. This amount,
, of the
$
bill was paid by

state:

$

Amount Paid

$

Amount Due

$

relationship:
zip:

Enter name, address, and relationship to deceased.
name:
city:
line 1:

line 2:

Total Bill

ctry:
relationship:

zip:

ctry:

Certification
I certify that this concern performed the above services and that no further part of this bill has been paid.
It is therefore requested that payment, in accordance with the Longshore and Harbor Workers' Compensation Act or
its extensions, be paid for the services indicated above.
8. Signature and title (Type and sign)

9. Date signed

Public Burden Statement
We estimate that it will take an average of 15 minutes to complete this collection of information, including 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 these estimates or any other aspect of this collection of information, including suggestions for reducing
this burden, send them to the U.S. Department of Labor, Division of Longshore and Harbor Workers' Compensation, Room C4315, 200
Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND COMPLETED FORMS TO THIS OFFICE.
Form LS-265
Rev. May 2002