U.S. Department of Labor Claim For Reimbursement Assisted Reemployment Employment Standards Administration Office of Workers' Compensation Programs Instructions: Complete items 1 through 16 and send to the Division of Rehabilitation. If item 5 does not apply to you leave it blank. No further monies may be paid out under this program unless this report is completed and filed, as required by terms of the Cooperative Agreement entered into by you and OWCP. (P.L. 106.554) 1. Employer's Name 2. Phone Number 3. Employer's Complete Mailing Address: OMB No. 1215-0178 Expires: 06-30-2010 4. Employer's Tax I.D. No. 5. Employer (Federal) Appropriations Code Street or Post Office Box Number City ZIP Code State 7. OWCP File Number 6. Claimant's Name Last M.I First 8. Social Security Number 10. Reporting Quarter 9. Date Employment Began Month 11. Dates and Hours Worked Day 12. Pay Rate Per Hour Year 13. Total Amount Earned 14. Amount of Reimbursement Claimed I certify that the information provided on this form is true and correct to the best of my knowledge. 16. Date 15. Supervisor's Signature For OWCP Use Only Below This Space: Percentage Allowed: % Total Amount This Payment $ Authorized by: Date: Public Burden Statement We estimate that it will take an average of 30 minutes per response to complete this information collection, including the 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 burden estimate or any other aspect of the survey, including suggestions for reducing this burden, send them to the U.S. Department of Labor, Office of Workers' Compensation Programs, Room S3229, 200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED SURVEY TO THE ABOVE OFFICE Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Form CA-2231 June 2004 American LegalNet, Inc. www.FormsWorkflow.com