Employment Standards Administration U.S. Department of Labor Office of Workers' Compensation Programs Longshore and Harbor Workers' Compensation Division of Longshore and Harbor Workers' Compensation OWCP File No: Claimant: Injury Date: OMB No. 1215-0112 Expires: 06/30/2012 Dear Mr/Ms ___________________________________: Our records indicate that you are or were receiving compensation at the rate of $____________ per week based on earnings reported by your employer. If you feel that you are entitled to a higher compensation rate, you may submit a record of your earnings from all types of employment for the 52 weeks prior to your injury. You may also provide reasons why your benefit rate should not be based on earnings in the year prior to your injury alone. Please use the back of this form for this purpose. Please submit documentation of earnings such as W2s, wage slips or statement from your employer. Please send the requested information to the office address shown above within 30 days. We will review the earnings information you provide to determine whether the compensation rate is accurate. Sincerely, Enclosure PRIVACY ACT OF 1974 NOTICE In accordance with the Privacy Act of 1974, as amended, (5 U.S.C. 522a), you are hereby notified that: (1) The Longshore and Harbor Workers' Compensation Act (LHWCA), as amended and extended (33 U.S.C. 901 et seq.) LHWCA is administered by the Office of Workers' Compensation Programs of the U.S. Department of Labor which receives and maintains information on claimants and their immediate families. (2) Information which the Office has will be used to determine eligibility for the amount of benefits under the LHWCA. (3) Information may be given to 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. (4) Information may be given to the 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. (5) Information may be given to 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. (6) Information may be given to 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. (7) 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. Note: The notice applies to all forms requesting information that you might receive from the Office in connection with the processing and/or adjudication of the claim you filed under the LHWCA and related statutes. This form letter is used to request earnings information. The information will be used to determine the correct compensation rate. Submission of the report is required to obtain payment at the correct rate (33 USC 910). Include your address, ZIP code, and file number on all correspondence. Form LS-426 Rev. November 2008 American LegalNet, Inc. www.FormsWorkFlow.com 2 OWCP File No: ________________ Claimant: Note: Earnings for several months may be grouped if desired. 20___ Name of Employer Occupation Amount Earned Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 20____ Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Signature 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 15 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. The obligation to respond to this collection is required to obtain or retain benefits. The authority for requesting this information is 33 USC 910. 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, Division of Longshore and Harbor Workers' Compensation, Room C-4315, Washington, D.C. 20210, and reference the OMB Control Number (1215-0112). Note: Please do not return the completed LS-426 to this address. American LegalNet, Inc. www.FormsWorkFlow.com