Claimant's Statement

Claimant's Statement                                      Print      Reset           U.S. Department Of Labor
                                                                                     Office of Workers' Compensation Programs


Loss of compensation benefits may result if this report is not completed and filed in accordance with instructions (33 U.S.C. 944).               OMB 1240-0014
                                                                                                                                                  Expires: 11/30/2026
1.                                                                                                                      2. OWCP No.
                                  Place within brackets



                                                                                                                        3. Carrier's No.
                                                                                          Name and Address of
                                                                                          Beneficiary (Type or print)


                                                                                                                        Telephone Number
                                           United States



4. If you are receiving death benefits as a surviving spouse, please state whether you have remarried.                  5. If payments are being made on behalf
                                                                                                                        of a beneficiary as a student, is the bene-
      Yes                   No    If ''Yes'', give name of spouse and date of marriage.
                                                                                                                        ficiary still enrolled in school as a full-
                                                                                                                        time student?
                                                                                                                                                Yes                 No

I hereby acknowledge receipt of compensation from the U.S. Department of Labor, Division of Federal Employees', Longshore and Harbor Workers' Compensation,
and certify that the above information is true and correct.




                         (Signature)                                                      (Name of Signer)                                                 (Date)

Important Notice: Section 31 (a)(1) of the Longshore Act, 33 U.S.C. 931 (a)(1), provides as follows: Any claimant or representative of a claimant
who knowingly and willfully makes a false statement or representation for the purpose of obtaining a benefit or payment under this Act shall be guilty of a
felony, and on conviction thereof shall be punished by a fine not to exceed $10,000 by imprisonment not to exceed five years, or by both.


                                                          TO SUBMIT FORMS TO DEPARTMENT OF LABOR
                                                                with the exception of DCCA cases

            Please be sure to include the OWCP Case Number and mail to the OWCP/DLHWC Central Mail Receipt site at the following address:
                                                                   U.S. Department of Labor
                                                         Office of Workers' Compensation Programs
                                       Division of Federal Employees’, Longshore and Harbor Workers' Compensation
                                                           400 West Bay Street, Suite 63A, Box 28
                                                                    Jacksonville, FL 32202

                                 Or upload the form directly to the case file using our Secure Electronic Access Portal (SEAPortal).

                                                  Access the SEAPortal directly at https://seaportal.dol.gov/portal/




                                                                                                                                                        Form LS-267
                                                                                                                                                        Rev. Nov 2023
                                                          Public Burden Statement
We estimate that it will take an average of 2 minutes to complete this information collection including time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. If you have any comments
regarding these estimates or any other aspect of this information collection, including suggestions for reducing this burden, send them to the
U.S. Department of Labor, Division of Federal Employees', Longshore and Harbor Workers' Compensation, Room S-3229, 200 Constitution
Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE


This form is used to collect information relating to the payment of death benefits. The information provided will be used to determine
entitlement to death benefits. Persons are not required to respond to the collection of information unless it displays a currently valid
OMB Control Number.




                                                                                                                                            Form LS-267
                                                                                                                                           Rev. Nov 2023
                                                                                                                                                  Page 2