LS-5 Application for Special Fund Relief

U.S. Department of Labor

Application for Special Fund Relief

Office of Workers' Compensation Programs

INSTRUCTIONS: You must use this form to request Special Fund relief under Section 8(f) of the
Longshore and Harbor Workers' Compensation Act, 33 U.S.C. 908(f), and extensions. You must
attach supporting documentation as described in 20 CFR 702.321(a) and file the application within the
time limits set forth in 20 CFR 702.321(b).

OMB No.: 1240-0058
Expires: 03/31/2023

Or upload directly to the case file using the
Submit form to the OWCP/DFELHWC Central Mail Receipt site
Secure Electronic Access Portal (SEAPortal)
at the following address:
U.S. Department of Labor, Office of Workers' Compensation Programs
Access the SEAPortal directly at:
DFELHWC
https://seaportal.dol.gov/portal/
400 West Bay Street, Suite 63A, Box 28
Jacksonville, FL 32202
1. Date of Accident/Illness:

2. Carrier's No.

3. OWCP No.

4. Name of Injured Worker and Claimant if other than injured worker

5. Explain how limitation of liability under Section 8(f) would apply to this injury.

6. Describe the nature of the injury, and disability/death:

7. List documentation to show extent of disability and date of maximum medical improvement, if applicable:

8. List documentation of pre-existing disability(ies) manifest to employer:

9. List evidence that explains how injury is not the sole cause of disability/death, and if permanent partial disability, how disability is
substantially greater as a result of the manifested pre-existing disability(ies) listed above:

10. List any pending issues/disputes:

11. 8(f) Relief is sought for:

Permanent Total Disability (PTD)

Permanent Partial Disability (PPD) - Hearing Loss

Permanent Partial Disability (PPD)
12. If PPD, list documentation establishing injured workers' earning capacity:

Do NOT attach or submit irrelevant records.

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Form LS-5

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 burden for this collection of information is
estimated to average 20 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. Use
of this form is required to request approval of Special Fund Relief by the Office of Workers’ Compensation Longshore
Program under 33 U.S.C. 908(f) and 20 C.F.R. 702.321. 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, 200 Constitution Avenue, NW, Room S-3524, Washington, D.C. 20210 and reference the OMB Control
Number. Note: Please do not return the completed LS-5 to this address.

DO NOT SEND COMPLETED FORMS TO THIS OFFICE.
PRIVACY ACT STATEMENT
The following information is provided in accordance with the Privacy Act of 1974, as amended, 5 USC 552a. (1) This
collection of information is authorized under the Longshore and Harbor Workers’ Compensation Act (LHWCA) and its
extensions. (2) This information will be used to determine if Special Fund Relief will be granted under the LHWCA.
(3) Completion of this form is required to request Special Fund relief by the Office of Workers’ Compensation
Longshore Program. (4) Disclosures of this information may be made to: the claimant and his or her
representative(s); the employer, the insurance carrier or other entity that secured the employer’s compensation
liability, and their representative(s); the Department of Labor’s Office of Administrative Law Judges (OALJ), or other
person, board or organization, authorized or required to render decisions on claims or other matters arising in
connection with a claim; Federal, state and local agencies 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; and other individuals, their representatives, and government agencies enforcing a legal obligation for
alimony or child support. (5) Failure to provide the information on this form may delay processing of the Special Fund
application or result in the denial of Special Fund relief. (6) This information is included in two Systems of Records,
DOL/OWCP-3, 4, published at 81 Federal Register 25765, 25859-61 (April 29, 2016), or as updated and republished.

Form LS-5
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