Claimant's Statement
U.S. Department Of Labor
Office of Workers' Compensation Programs
Loss of compensation benefits may result if this report is not completed and filed in accordance with instructions (33 U.S.C. 944).
OMB 1240-0014
2. OWCP No.
Place within brackets
Name and Address of
Beneficiary (Type or print)
3. Carrier's No.
5. If payments are being made on behalf
of a beneficiary as a student, is the bene-
ficiary still enrolled in school as a full-
time student?
No If ''Yes'', give name of spouse and date of marriage.
Yes
Yes
No
(Date)
(Signature)
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 on conviction thereof shall be punished by a fine not to exceed $10,000 by imprisonment not to exceed five years, or by both.
Form LS-267
Rev. March 2012
1.
4. If you are receiving death benefits as a surviving spouse, please state whether you have remarried.
I hereby acknowledge receipt of compensation from the U.S. Department of Labor, Division of Longshore and Harbor Workers' Compensation, and
certify that the above information is true and correct.
(Name of Signer)
Telephone Number
