Form LS-265 Certification of Funeral Expenses

U.S. Department of Labor

Certification of Funeral Expenses
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Office of Workers' Compensation Programs
Division of Longshore and Harbor Workers' Compensation

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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
OMB No. 1240-0040
form is required to obtain payment for services performed (20 C.F.R. § 702.121.) The DOL makes no assurances of confidentiality to Expires: 10/31/2023
respondents. As a practical matter, the DOL would only disclose information collected under these requests in accordance with the
provisions of the Freedom of Information Act, 5 U.S.C. § 552; the Privacy Act, 5 U.S.C. § 552a; and related regulations, 29 C.F.R.
parts 70, 71.
1. OWCP No.

3. Name of deceased

2. Carrier's No.
4. Funeral Director (Name, address, ZIP code)

Services Performed
(itemize below and enter costs)

5.

Comments

(If additional space is required continue on reverse)
6. I was informed
that the above
bill would be
paid by

Enter name, address, and relationship to deceased.

7. This amount,

Enter name, address, and relationship to deceased.

$
bill was paid by

Total Bill

$

Amount Paid

$

Amount Due

$

, of the

Certification
I certify that this company 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)

Phone Number

9. Date signed

Please be sure to include the OWCP Case Number and mail this form to the OWCP/DLHWC Central Mail Receipt site at the following address: U.S. Department
of Labor Office of Workers' Compensation Programs Division of Longshore and Harbor Workers' Compensation 400 West Bay Street, Suite 63A, Box 28
Jacksonville, FL 32202. Or upload the claim directly to the case file using the Secure Electronic Access Portal (SEAPortal). Access the SEAPortal directly at:
https://seaportal.dol-esa.gov
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 a valid OMB
control number. Public reporting burden for this collection of information is estimated to average 15 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 optional, however furnishing the information is required in order to obtain and/or retain benefits (20CFR 702.121). 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, N.W., Room S-3229, Washington, D.C. 20210, and reference the OMB Control Number. DO NOT SEND COMPLETED FORMS TO THIS OFFICE.
Form LS-265

Rev. August 2020