Statement of Recovery

Statement of Recovery Forms

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0001 can be found here:

Documents and Forms

Document Name Document Type
Form CA-1122 Statement of Recovery Form and Instruction
CA-1122 Statement of Recovery ca-1122 final.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction
CA-1122 Statement of Recovery ca-1122 final.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction

Information Collection (IC) Details

IC Title:	Statement of Recovery	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 10.710 20 CFR 10.707 (e)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CA-1122	Statement of Recovery	ca-1122 final.pdf	https://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Central Personnel

Privacy Act System of Records
Title: DOL/GOVT-1 (Office of Worker's Compensation Programs, Federal Employees' Compemsation Act File	FR Citation: 81 FR 47418

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 97 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10	0	10
Annual IC Time Burden (Hours)	3	0	3
Annual IC Cost Burden (Dollars)	0	-3	3

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.