Report of Earnings (Longshore and Harbor Workers' Compensation Act, as Extended) U.S. Department of Labor Office of Workers' Compensation Programs www.dol.gov/owcp/dlhwc/index.htm OMB No.: 1240-0014 Instructions to Employee: You are required to complete and sign this form and return it to the employer/ insurance carrier/ special fund listed in item 4 within 30 days after receipt even if you have no earnings to report. (20 CFR 702.286) See page 2 for definition of "Earnings" and additional instructions. Loss of compensation benefits may result if this form is not completed and filed in accordance with instructions. 1. last name line1 line2 city st country United States 4. Name of Employer/Insurance Carrier/ Special Fund zip first mi. Name and Address of Employee (Type or print) 3. Carrier's No. 2. OWCP No. 5. Address of Employer/ Insurance Carrier/ Special Fund line1 line2 city st zip 6. Period for which earnings from employment or selfemployment must be reported From To 7. Have you had any earnings from employment or self-employment during the period shown in item 6? (See page 2 for definition of "earnings") Yes No 8. Complete the following if you had earnings from employment during the period shown in item 6. Periods of Employment Name and Address of Employer To From name city st name city st name city st zip zip zip Amount Earned 9. Complete the following if you had earnings from self-employment during the period shown in item 6. Type of Business or Service Dates Performed From To Gross Revenue Received Profits or Net Earnings Received 10. I certify that the above information I have provided is true, complete and correct to the best of my knowledge and belief. Signature Print Name 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 conviction thereof shall be punished by a fine not to exceed $10.000, by imprisonment not to exceed five years, or both. Form LS-200 Rev. April 2009 Telephone No. Date American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS TO EMPLOYEE You are required to report on this form all earnings from employment or self- employment earned during the period specified on page 1 of this form (20 CFR 702.286). An employee who fails to report his/her earnings when requested or knowingly and willfully omits or understates any part of such earnings may forfeit his/her right to compensation with respect to any period during which this report is required. Compensation forfeited, if already paid, shall be deducted from any future compensation which may be due in accordance with a schedule determined by the District Director of the Office of Workers' Compensation Programs, Division of Longshore and Harbor Workers' Compensation, having jurisdiction in the case. (33 U.S.C. 908(j). Earnings are defined as all monies received from any employment and includes but is not limited to wages, salaries, tips, sales commissions, fees for services provided, piecework and all revenue received from self- employment even if the business or enterprise operated at a loss or if the profits were reinvested. An employer, insurance carrier, or the Director of the Office of Workers' Compensation Programs, Division of Longshore and Harbor Workers' Compensation (for those cases being paid from the Special Fund) may require an employee to file this report semiannually. The information provided will be used to determine entitlement to benefits. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. FAILURE TO GIVE WRITTEN NOTICE MAY RESULT IN SOME LOSS OF BENEFITS. PRIVACY ACT STATEMENT Privacy Act of 1974 as amended (5 U.S.C. 552a), section 901 of Title 33 to the US Code and 20 CFR 702.285 authorizes collection of this information. The purpose of this information is to determine eligibility for the amount of benefits payable under the Longshore and Harbor Workers' Compensation Act (LHWCA). Completion of this form is not mandatory; however, failure to provide the information may result in the loss of compensation benefits. Additional disclosures of this information may be to: (1) the employer which employed the claimant at the time of injury, or to the insurance carrier or other entity which secured the employer's compensation liability. (2) Physicians and other medical service providers for use in providing treatment or medical/vocational rehabilitation, making evaluations and for other purposes relating to the medical management of the claim. (3) the Department of Labor's Office of Administrative Law Judges (OALJ), or other person, board or organization, which is authorized or required to render decisions with respect to the claim or other matter arising in connection with the claim. (4) Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the LHWCA 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. (5) Failure to disclose all requested information may delay the processing of the claim, the payment of benefits, or may result in an unfavorable decision or reduced level of benefits. 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 reporting burden for this collection of information is estimated to average 10 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 optional, however furnishing the information is required in order to obtain and/ or retain benefits. (20 CFR 702.285). Send comments regarding the burden estimated 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 C-4315, Washington, D.C. 20210 and reference the OMB Control number. American LegalNet, Inc. www.FormsWorkFlow.com