Form CA-1122 Statement of Recovery

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U.S. DEPARTMENT OF LABOR

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

OMB No. 1240-0001
Expiration Date: 11-30-2018
File Number:
Employee:

SHORT FORM STATEMENT OF RECOVERY
(See following page for instructions)*
Date of judgment or release:
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 for Loss of Consortium, if any
(Line 4 is
% of Line 3)
5. Subtotal B (Line 3 minus Line 4)
6. Enter 20% of Line 5
7. Balance (Line 5 minus Line 6)
8. Enter Refundable Disbursements
9. Enter lower of Line 7 or Line 8
REFUND THIS AMOUNT TO OWCP
10. Surplus (Line 7 minus Line 8)
If Line 8 is greater than Line 7, enter "0".
CREDIT AGAINST FUTURE BENEFITS

CA-1122 (Rev. 05-15)

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 -1122 are true, complete and correct
to the best of my knowledge and belief. 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

Date

(For use by OWCP only)
*Attorneys must use the Form CA-1108, Long Form Statement of Recovery.

Approved:

Date:
WARNING

A FALSE OR EVASIVE ENTRY ON FORM CA-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 CA-1122 ARE SUBJECT TO INVESTIGATION
FOR VERIFICATION.
Following your submission of the CA-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.

CA-1122 PAGE 2 (Rev. 05-15)

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 FECAcovered 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 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.

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-1122 PAGE 3 (Rev. 05-15)

INSTRUCTIONS FOR FORM CA-1122
*Distribution of the proceeds from the third-party recovery must be made in accordance with 5 U.S.C. 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 - PROPERTY DAMAGE - 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, along with an
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). 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%). The
approved allocation must be expressed as a percentage of the amount on Line 3 in the space provided. 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
Line 6 - 20% GUARANTEE - Multiply Line 5 by 20% and enter the result on Line 6. This amount is retained by
you and is not subject to any deductions.
Line 8 - OWCP DISBURSEMENTS - All amounts paid by OWCP (compensation and medical benefits, but not
continuation of pay (COP)) less the gross amount of any prior refunds made (from Line 7 on any earlier EN-1122
or CA-1122) are to be entered in the space provided.
Line 9 - REFUND TO OWCP - Compare Line 7 with Line 8 (refundable disbursements), and enter the lower of
the two on Line 9. This is the amount to be refunded to OWCP. NOTE: You must contact OWCP to obtain a
current history of the disbursements made to you and your medical providers for compensation and medical
benefits.
Line 10 - CREDIT AGAINST FUTURE BENEFITS (SURPLUS) - If Line 7 is less than Line 8 (Refundable
Disbursements), there is no credit to be applied against future benefits. If Line 7 is greater than Line 8, a credit
against future benefits must be applied and is determined by subtracting Line 8 from Line 7. 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 in Line 9 should be made payable to the "U.S. Department of Labor,
OWCP”. PLEASE INCLUDE THE OWCP FILE NUMBER ON THE CHECK.
Unless directed otherwise, send refund check to:
U.S. Department of Labor
Office of the Solicitor
200 Constitution Avenue NW
Room S4325
Washington, DC 20210.
CA-1122 PAGE 4 (Rev. 05-15)