Overpayment Recovery Questionnaire

Overpayment Recovery                               Reset          Print           U.S. Department of Labor
Questionnaire                                                                     Office of Workers’ Compensation Programs



Overpaid Person - Last Name                        First Name                              MI    Claim No.             OMB No.: 1240-0051
                                                                                                                        Expires: 03-31-2026
Claimant - Last Name                               First Name                              MI


EVERYONE MUST COMPLETE PART I, PART II, AND PART V,                       PART III       PART IV
COMPLETE THE FOLLOWING PARTS ONLY IF MARKED:

                             Part I - Possession of Overpayment (to be completed by all applicants for waiver)

1. Do you have any of the incorrectly paid checks or payments in your possession?
         Yes       No

  If “Yes”, show the total amount: $_____________________. (These funds should be returned to the U.S. Department of Labor immediately).

2. Since you were notified of the overpayment, have you transferred by loan, gift, sale, etc. any property or cash?     Yes      No
  If "Yes", explain:




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                                                     Part II - REFUND QUESTIONNAIRE
(To be completed by the person for whom repayment of the overpayment would cause undue hardship)
3. List your monthly income (Including any income of your spouse or any dependent                                           Monthly Income
relative living in the household with you) from:

Social Security Benefits                                                                                                      $

Supplemental Security Income Payment                                                                                          $

State or Local Welfare Payment. Specify:                                                                                      $

Other benefits, such as Veterans Administration, Civil Service, Unemployment, Black Lung, FECA,
Railroad, Private Pension, etc. Specify:                                                                                      $

Earnings (take-home wages and average net earnings from self-employment). Specify:                                            $

Other income, such as dividends, interest, rentals, roomers or boarders, etc. Specify:                                        $

                                                                                                     Total Monthly income                    $0.00
4. Do you support, either fully or in part, anyone other than yourself?
                                                                                               Yes      No
   If "Yes", give the following information about each person you support:
                                                                                                                         Relationship To You
                  Name                                               Address                                 Age
                                                                                                                       (If None, Enter "None")




5. List the usual expenses of your household on a monthly basis                                                                   Monthly Payment


  Rent or Mortgage, including Property Tax                                                                                    $

  Food                                                                                                                        $

  Clothing                                                                                                                    $

  Utilities (electricity, gas, fuel, telephone, water)                                                                        $

  Other expenses (Such as: Miscellaneous household expenses, medical and dental care (not                                     $
  covered by insurance), automobile expenses or other transportation costs, personal necessities.)

                                                    Other Debts Being Paid By Monthly Installments

                                 Creditor                                           Amount Owed                       Monthly Payment

                                                                           $                                   $


                                                                           $                                   $


                                                                               Total Monthly Expenses                                        $0.00

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6. Not counting your home, family automobile, or household furnishings,                      Yes      No
do you or your spouse own any valuable property or real estate?
  If "Yes", specify and give current market value. If mortgage, show amount of mortgage.




7. List below any funds you have (including those of your spouse, if you live with your spouse):

                                           a. Cash on hand                                                                $

                                           b. Checking account balance                                                    $

                                           c. Savings account balance                                                     $

                                           d. Current value of any stocks and bonds                                       $

                                           e. Value of other personal property and other funds                            $

                                                                                      TOTAL                                            $0.00

     f. Name of stocks and bonds you have (use separate sheet if       g. Name and address of financial institutions(s)
     space is insufficient).




                                                   PART III - WITHOUT FAULT STATEMENT

8. Explain fully why you thought the incorrect payment was due to you and why the overpayment was not your fault:




9. Did you report the change in circumstances which affected your monthly payment?           Yes         No        There was no change
If "Yes", when did you report? (Give date):

If "No", why didn't you report?




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10. When were the conditions under which you could receive payments first explained to you?




11. Do you NOW fully understand reporting responsibilities?         Yes        No   If "No", explain:




                                              PART IV - REPRESENTATIVE PAYMENT MADE
                                            (to be completed ONLY by a representative payee)

12. Give the name and present address of the person for whom you received payment:




13. Were the incorrect payments used for this person?         Yes         No

Explain:




                                                                    PART V

14. Remarks (optional):




  I know that anyone who makes or causes to be made a false statement or representation of material fact in an application or for use in
  determining a right to payment under the BLBA, EEOICPA and FECA commits a crime punishable under Federal and/or State law. I affirm
  that all information I have given in this document is true.




     (Signature of Overpaid Person or Representative Payee)                                        (Date - Month, day, year)




                                                                                                        (Telephone Number)


   Mailing Address (Number and Street, Apt. No., P.O. Box, Rural Route)




   City                                     State             Zip                   County (if any) in which you now live:



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                                                      Privacy Act Statement

              Collection of this information by OWCP is authorized by section 8129(b) of the Federal Employees'
              Compensation Act (5 USC 8129(b)), section 413(b) of the Black Lung Benefits Act (30 USC 923(b)) and
              section 7385j-2 of the Energy Employees Occupational Illness Compensation Program Act (42 USC
              7385j-2). The information provided will be used to determine the extent to which overpayments of
              benefits will be recovered and is fully protected by the Privacy Act of 1974, as amended (5 USC 552a)
              under the following systems of records: DOL/GOVT-1, published in the Federal Register, Vol. 81, page
              47418, July 21, 2016, DOL/OWCP-2, DOL/OWCP-9, and DOL/OWCP-11, published in the Federal
              Register, Vol. 81, page 25766, April 29, 2016, or as updated and republished. This information may be
              disclosed to private collection agencies under contract with the Departments of Labor, Justice or
              Treasury, or to the Department of Justice for litigation purposes. Additional disclosures may be made
              through the routine uses for information contained in the referenced systems of records.

                                                     Public Burden Statement

              Under the Paperwork Reduction Act, persons are not required to respond to a collection of information
              unless such collection displays a valid OMB control number. Completion and submission of this form is
              voluntary; however, failure to provide the information may result in the denial of a request to waive
              recovery of the overpayment. We estimate that it will take an average of 60 minutes to complete this
              collection of information, including time for reviewing instructions, searching existing data sources,
              gathering and maintaining the data needed, and completing and reviewing the collection of information.
              If you have any comments regarding this estimate or any other aspect of this collection of information,
              including suggestions for reducing this burden, send them to the Direct or , U.S. Department of Labor,
              Office of Workers’ Compensation Programs, Room S- 3524, 200 Constitution Avenue NW, Washington,
              DC 20210. DO NOT SEND THE COMPLETED FORM TO THIS ADDRESS.


                                                    Accommodation Statement

              If you have a disability and are in need of communication assistance (such as alternate formats or sign
              language interpretation), accommodations and/or modifications, please contact OWCP.




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