Form ca-1108 Statement of Recovery

U.S. DEPARTMENT OF LABOR
Print

Office of Workers’ Compensation Programs
Division of Federal Employees’ Compensation

OMB No. 1240-0001
Expiration Date: XX-XX-XXXX

Reset

File Number:

Employee:
LONG FORM STATEMENT OF RECOVERY
(See following pages for instructions)

1. Gross Recovery (Entire Amount of the Award)

$

2. Amount of Real or Personal Property Damage (Must be approved)
3. Subtotal A (Line 1 minus Line 2)
4. Amount Allocated for Loss of Consortium (

% of Line 3)

5. Subtotal B (Line 3 minus Line 4)
6. Amount Allocated for Wrongful Death* (
7. Amount Allocated for Survival Action* (

% of Line 5)
% of Line 5)

8. Subtotal C (for Wrongful Death enter Line 6;
for a Survival Action enter Line 7; if neither enter Line 5)
9. Attorney’s Fees (

% of Line 8)

10. Subtotal D (Line 8 minus Line 9)
11. Court Costs (Adjustments are made for loss of consortium,
wrongful death and survival actions, see instructions)

12. Subtotal E (Line 10 minus Line 11)
13. 20% of Subtotal E (Line 12 x .20)
14. Subtotal F (Line 12 minus Line 13)
15. Refundable Disbursements
16. Subtotal G (Lower of Line 14 or Refundable Disbursements)
17. Government’s Allowance for Attorney’s Fees (% on Line 9 x Line 16)
18. Refund to the United States (Line 16 minus Line 17)
19. Credit Against Future Benefits (Surplus) (If Line 14 is greater than
Line 15, then Line 14 minus Line 15, otherwise enter “0”)
* (NOTE: If the recovery was from both a Wrongful Death action and a Survival action, a separate CA-1108 must
be prepared for each cause of action.)

CA-1108 (Rev. 02-12)

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 this Form CA-1108 are true, complete and correct to the best of my
knowledge and belief, and I have placed “Not Applicable (N/A)” or “None” next to those entries that do not apply
to this case. I also certify that the information on this form does/does not (circle one) represent my settlement
with all defendants in the case, and that I have/do not have (circle one) other cases or claims pending or
unresolved against any other third parties liable for the same injuries for which FECA benefits have been paid or
are payable.

Signature of Beneficiary or Authorized Representative

Date

Print Name

(This space for use by the Dept. of Labor or U.S. Postal Service only)
Approved:

Date:
WARNING

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

CA-1108 PAGE 2 (Rev. 02-12)

PRIVACY ACT STATEMENT
The following statement is made in accordance with the Privacy Act of 1974 (5. U. S. C. 552a). 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 and 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.

NOTICE
If you have a disability (a substantially limiting physical or mental impairment), please contact our office/claims
examiner for information about the kinds of help available such as communication assistance (alternate formats or
sign language interpretation), accommodations and modifications.

CA-1108 PAGE 3 (Rev. 02-12)

INSTRUCTIONS FOR FORM CA-1108
*Distribution of the proceeds from the third party recovery must be made in accordance with 5 U.S.C. section
8132.*
Line 1- GROSS RECOVERY – The entire amount of any award received as a result of a judgment entered in a
lawsuit, settlement of a lawsuit, or any other settlement or recovery from a responsible third party, must be entered
on Line 1 as the gross recovery.
Line 2 - REAL OR PERSONAL PROPERTY DAMAGE – A reasonable amount for real or personal property, such
as 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, along with your insurance company’s estimate of the damage
declaring the vehicle to be a total loss. A copy of the repair bill will suffice if the vehicle was not totally destroyed.
Line 4 - LOSS OF CONSORTIUM – OWCP or SOL (or whoever else has been delegated the authority) will
determine a reasonable allocation of the judgment or settlement for loss of consortium, unless the judgment is
from a contested verdict, then those allocations will be used. The amount allocated for loss of consortium must be
a percentage of the amount on Line 3, and must be approved by OWCP or SOL (or other delegated authority). In
a non-death case or a death case where no cause of action for wrongful death is asserted, a reasonable allocation
for a spouse’s loss of consortium will be up to 25% of Line 3 and for a child or children’s loss of consortium up to
5% per child, to a maximum of 15% for all children of Line 3 (total combined 40%). In a death case alleging
wrongful death, a reasonable allocation for a spouse’s loss of consortium will be up to 15% of Line 3 and for a
child or children’s loss of consortium up to 5% per child, to a maximum of 10% for all children for a child or
children’s loss of consortium (total combined 25%). In cases where loss of consortium has been asserted for both
a spouse and child or children, multiply the combined total by Line 3. The beneficiary must establish that loss of
consortium was asserted in the suit or claim, and that loss of consortium claims are permitted under the state law
where the action was brought. FECA beneficiaries may accept the determination of the percentage allocated or
demonstrate good cause in writing for a different percentage to be allocated for loss of consortium.
Lines 6 & 7 - WRONGFUL DEATH OR SURVIVAL – Amounts received where both wrongful death and survival
actions have been asserted must be allocated between the two actions, and separate CA-1108s must be filed for
each cause of action. OWCP or SOL will determine a reasonable allocation of the judgment or settlement for the
wrongful death action and the survival action, unless the judgment is from a contested verdict, then those
percentages will be used. The amount allocated for wrongful death and survival must be a percentage of the
amount on Line 5 and must be approved by OWCP or SOL. For a wrongful death action, a reasonable allocation
is 65% of the amount on Line 5. For a survival action, a reasonable allocation is 35% of the amount on Line 5.
FECA beneficiaries may accept the determination of the percentage allocated or demonstrate good cause in
writing for different percentages to be allocated for wrongful death and survival.
Line 9 - ATTORNEY'S FEES – Reasonable attorney’s fees, but not more than the fee actually paid, may be
deducted from Subtotal C. OWCP and SOL (or whoever else has been delegated the authority) determines what
is a reasonable attorney fee. The fee must be expressed as a percentage. The percentage will be calculated by
dividing amount of the total fee charged by the amount of gross recovery in Line 1 (total fee/gross recovery). The
percentage used must be entered in the designated space. Multiply Line 8 (Subtotal C) by the attorney’s fees
percentage entered in the space on Line 9, and enter the result on the same line.
Line 11 - COURT COSTS - These consist of such items as filing fees, witness fees, actual costs of collection, or
any payments for expert testimony. They do not include such items as payments for overhead or medical
treatment. COURT COSTS MUST BE ITEMIZED AND APPROVED BY OWCP OR SOL (OR WHOEVER ELSE
HAS BEEN DELEGATED THE AUTHORITY). Court costs must be reduced by the percentage attributable to the
loss of consortium claim or wrongful death and survival actions. If only loss of consortium is claimed, multiply the
total court costs by the percentage entered on Line (4) and subtract that amount from the total court costs and
enter the new total on Line (11). For example if court costs are $48,000 and the allocation is 25% for loss of
consortium, the court costs would be $48,000 – ($48,000 x .25).
CA-1108 PAGE 4 (Rev. 02-12)

If wrongful death and survival actions are asserted but there is no loss of consortium claim, for the wrongful death
CA-1108, multiply the total court costs by the percentage used for the survival action and subtract this amount
from the total court costs and enter the new total on Line (11); for the survival action CA-1108, multiply the total
court costs by the percentage used the wrongful death action and subtract this amount from the total court costs
and enter the new total on Line (11). For example, if court costs are $48,000 and the allocation is 65% for
wrongful death and 35% for survival, the wrongful death CA-1108 should reflect court costs as $48,000 – ($48,000
x .35) and the survival action CA-1108 should reflect costs of $48,000 – (48,000 x .65).
If wrongful death and survival actions are asserted in addition to loss of consortium, the costs of litigation are
reduced first by the percentage used for loss of consortium and then reduced by the percentage used for wrongful
death and survival. For example, if court costs are $48,000 and the allocation is 25% for loss of consortium, 65%
for wrongful death, and 35% for survival, the court costs for the wrongful death CA-1108 would be $48,000 –
($48,000 x .25) = $12,000 and then (48,000 - 12,000) x .35 = $12,600, resulting in $48,000 - $12,000 - $12,600 =
$23,400. The court costs for the survival CA-1108 would be $48,000 – ($48,000 x .25) = $12,000 and then
(48,000 - 12,000) x .65 = $23,400 resulting in $48,000 - $12,000 - $23,400 = $12,600.
Line 13 - 20% GUARANTEE – Multiply Subtotal E by 20% (.20). This amount is turned over to the claimant and is
not subject to any deductions.
Line 15 - REFUNDABLE DISBURSEMENTS – Enter all amounts paid by OWCP (for compensation and medical
benefits but not Continuation of Pay), less any amounts of refundable disbursements listed on any prior Forms
EN-1108 or CA-1108, in the space provided.
Line 16 - SUBTOTAL G – Compare Subtotal F (Line 14) with the refundable disbursements (Line 15), and enter
the lower of the two on Line 16. The lower amount is Subtotal G.
Line 17 - GOVERNMENT ALLOWANCE FOR ATTORNEY'S FEES – The Government contributes a portion of
its refund to the claimant toward payment of attorney’s fees. This is computed by multiplying Subtotal G (Line 16)
by the attorney’s fees percentage entered on Line 9.
Line 18 - REFUND AMOUNT – (Line 16 minus Line 17) - This balance is the amount to be refunded to the
Government for OWCP disbursements.
Line 19 - CREDIT AGAINST FUTURE BENEFITS (SURPLUS) – If Subtotal F (Line 14) is less than the
Refundable Disbursements (Line 15), there is no credit to be applied against future benefits. If Subtotal F (Line
14) is greater than the refundable disbursements (Line 15), a credit against future benefits must be applied and is
determined by subtracting the refundable disbursements (Line 15) from Subtotal F (Line 14).The surplus is
retained by the claimant and is the amount against which OWCP will credit future compensation, including wage
loss compensation, schedule award benefits and medical expenses, on account of the same injury. OWCP will
resume payment of compensation only after the awarded compensation exceeds the amount of the surplus. For
this reason, 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 in Line 18 should be made payable to the "United States Department of
Labor, OWCP”.
Unless directed otherwise, send refund check to U.S. Department of Labor, Office of the Solicitor, 200 Constitution
Avenue NW S4325, Washington, DC 20210.

CA-1108 PAGE 5 (Rev. 02-12)