Request for Earnings Information Report

OMB 1240-0025

Report gathers information regarding an employee's average weekly wage. This information is needed for determination of compensation benefits in accordance with Section 10 of the Longshore and Harbor Workers' Compensation Act.

The latest form for Request for Earnings Information Report expires 2022-01-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form LS-426 Request for Earnings Information Form and Instruction
OMB - Supporting Statement for 1240-0025 (LS-426) 12.6.21 - FINAL.docx Supporting Statement A
33 USC 910.doc Supplementary Document
33 USC 908.doc Supplementary Document
Request for Earnings Information Form and Instruction

All Historical Document Collections

202106-1240-001 Approved without change	Extension without change of a currently approved collection	2021-12-10
202008-1240-065	No material or nonsubstantive change to a currently approved collection	2020-12-15
201807-1240-001 Approved without change	Extension without change of a currently approved collection	2018-10-01
201506-1240-013 Approved without change	Extension without change of a currently approved collection	2015-07-28
201506-1240-002 Approved without change	Revision of a currently approved collection	2015-06-05
201412-1240-007 Preapproved	No material or nonsubstantive change to a currently approved collection	2015-03-12
201409-1240-012 Approved without change	No material or nonsubstantive change to a currently approved collection	2014-09-30
201205-1240-002 Approved without change	Revision of a currently approved collection	2012-06-21
201003-1240-025 Approved without change	Extension without change of a currently approved collection	2010-03-12