Statement of Recovery Forms

OMB 1240-0001

These forms are used to obtain information about amounts received as the result of final judgments in litigation, or a settlement of the litigation, brought against a third party who is liable for damages due to a Federal employee comprehensive work-related injury.

The latest form for Statement of Recovery Forms expires 2022-02-28 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CA-1122 Statement of Recovery Form and Instruction
Form CA-1122 Statement of Recovery Form and Instruction
Form CA-1108 Statement of Recovery Forms Form and Instruction
Form CA-1108 Statement of Recovery Forms Form and Instruction
Justification for No material change CA-1108 and CA-1122_MN 4.23.2024.clean copy.docx Justification for No Material/Nonsubstantive Change
Justification for No material change CA-1108 and CA-1122_MN 4.23.2024.clean copy.docx Justification for No Material/Nonsubstantive Change
REVISED CA-1122 - SOL edits 4.17.24.pdf Supplementary Document
REVISED CA-1122 - SOL edits 4.17.24.pdf Supplementary Document
REVISED CA-1108 - SOL edits 4.17.24.pdf Supplementary Document
REVISED CA-1108 - SOL edits 4.17.24.pdf Supplementary Document
Supporting Statement 1240-0001 Clean 1.4.22.docx Supporting Statement A
Supporting Statement 1240-0001 Clean 1.4.22.docx Supporting Statement A
owcp feca privacy act system of records.docx Supplementary Document
owcp feca privacy act system of records.docx Supplementary Document
bls current employment statistics august 2020.docx Supplementary Document
bls current employment statistics august 2020.docx Supplementary Document
May 2020 Occupational Employment Statistics.docx Supplementary Document
May 2020 Occupational Employment Statistics.docx Supplementary Document
Statement of Recovery Form and Instruction
Statement of Recovery Form and Instruction
Statement of Recovery Forms Form and Instruction
Statement of Recovery Forms Form and Instruction

All Historical Document Collections

202404-1240-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2024-04-24
202109-1240-001 Approved without change	Extension without change of a currently approved collection	2022-01-11
201808-1240-001 Approved without change	Revision of a currently approved collection	2018-11-30
201609-1240-002 Approved without change	No material or nonsubstantive change to a currently approved collection	2016-09-12
201504-1240-001 Approved without change	Revision of a currently approved collection	2015-08-07
201202-1240-002 Approved without change	Revision of a currently approved collection	2012-05-11
201003-1240-001 Approved without change	Extension without change of a currently approved collection	2010-03-12

OMB Details

Statement of Recovery Forms

Federal Enterprise Architecture: Workforce Management - Labor Rights Management

Form CA-1108

Statement of Recovery

www.dol.gov/owcp/dfec/regs/compliance/forms.htm

Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.