Stipulation Approval Request

Stipulation Approval Request                                                   U.S. Department of Labor
                                                                               Office of Workers' Compensation Programs



You must use this form to request a District Director compensation order approving joint stipulations.         OMB No.: 1240-0058
You must attach the signed stipulations you want approved.                                                     Expires: 04/30/2029

Submit form to the OWCP/DLHWC Central Mail Receipt site                         Or upload directly to the case file using the
at the following address:                                                       Secure Electronic Access Portal (SEAPortal)
U.S. Department of Labor, Office of Workers' Compensation Programs
DLHWC                                                                           Access the SEAPortal directly at:
400 West Bay Street, Suite 63A, Box 28                                          https://seaportal.dol.gov/portal/
Jacksonville, FL 32202

If you have not already filed a service waiver, you should promptly submit an LS-801 or LS-802 form(s) to receive the
Order via email. The form(s) must be uploaded in SEAPortal separately.
1. Date of Accident/Illness:                     2. Carrier's No.                         3. OWCP No.


4. Name of Injured Worker and Claimant if other than injured worker



5. Average Weekly Wage:                                                    6. Compensation Rate

7. These Stipulations Include (check all that apply):

               Compensation              Medical Treatment            Attorney Fees


                   8. ENTER ALL PAYMENTS TO BE MADE PURSUANT TO THESE PROPOSED STIPULATIONS

                              FROM              THROUGH              AMOUNT PAID         NUMBER OF
TYPE OF DISABILITY         (Mo., day, yr.)     (Mo., day, yr.)        PER WEEK           WEEKS PAID                     TOTAL
          a.                     b.                  c.                   d.                 e.                            f.




9. Amount Due for Attorney fee:

10. Check if Additional Compensation will be paid as a result of these Stipulations:

11. Additional Information (optional):




                                                             Print         Reset                                                Form LS-9
                                          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 valid OMB control number. Public burden for this collection of
    information is estimated to average 20 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 required to obtain a compensation order approving
stipulations from the Office of Workers’ Compensation Longshore Program. See 20 C.F.R. 702.315(a). 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, NW, Room
  S-3524, Washington, D.C. 20210 and reference the OMB Control Number. Note: Please do not return the
                                          completed LS-9 to this office.




                                        PRIVACY ACT STATEMENT

 The following information is provided in accordance with the Privacy Act of 1974, as amended, 5 USC 552a.
 (1) This collection of information is authorized under the Longshore and Harbor Workers’ Compensation Act
  (LHWCA) and its extensions. (2) The information will be used to determine whether a compensation order
 should be issued based on stipulations entered into by the parties to a LHWCA claim. (3) Completion of this
       form is required to obtain a compensation order approving stipulations from the Office of Workers’
Compensation Longshore Program. (4) Disclosures of this information may be made to: the claimant and his
    or her representative(s); the employer, the insurance carrier or other entity that secured the employer’s
  compensation liability, and their representative(s); the Department of Labor’s Office of Administrative Law
 Judges (OALJ), or other person, board or organization, authorized or required to render decisions on claims
  or other matters arising in connection with a claim; Federal, state and local agencies to determine whether
benefits are being and have been paid properly and, where appropriate, to pursue salary/administrative offset
   and debt collection actions required or permitted by law; and other individuals, their representatives, and
   government agencies enforcing a legal obligation for alimony or child support. (5) Failure to provide the
   information on this form may delay processing of the claim, the payment of benefits, or may result in an
unfavorable decision or reduced level of benefits. (6) This information is included in two Systems of Records,
   DOL/OWCP-3, 4, published at 81 Federal Register 25765, 25859-61 (April 29, 2016), or as updated and
                                                   republished.




                                                                                                                 Form LS-9
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