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).
INSTRUCTIONS TO EMPLOYEE
Public Burden Statement
PRIVACY ACT STATEMENT
FAILURE TO GIVE WRITTEN NOTICE MAY RESULT IN SOME LOSS OF BENEFITS.
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.
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.
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.
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.
