Certification of Funeral Expenses
U.S. Department of Labor
Office of Workers' Compensation Programs
OMB No. 1240-0040
Expires: 08-31-2020
For Office Use
1. OWCP No.
2. Carrier's No.
The information provided on this form will be used to determine the amount of funeral expenses that are payable.
Completion of the form is required to obtain payment for services performed (20 C.F.R. § 702.121.) The DOL
makes no assurances of confidentiality to respondents. As a practical matter, the DOL would only disclose
information collected under these requests in accordance with the provisions of the Freedom of Information Act,
5 U.S.C. § 552; the Privacy Act, 5 U.S.C. § 552a; and related regulations, 29 C.F.R. parts 70, 71.
3. Name of deceased
4. Funeral Director (Name, address, ZIP code)
5.
Services Performed
(itemize below and enter costs)
Total Bill
$
Amount Paid
$
Amount Due
$
Comments
(If additional space is required continue on reverse)
Enter name, address, and relationship to deceased.
6. I was informed
that the above
bill would be
paid by
Enter name, address, and relationship to deceased.
7. This amount,
, of the
$
bill was paid by
Certification
I certify that this concern performed the above services and that no further part of this bill has been paid.
It is therefore requested that payment, in accordance with the Longshore and Harbor Workers' Compensation Act or
its extensions, be paid for the services indicated above.
9. Date signed8. Signature and title (Type and sign)
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
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. Use of this form is optional, however furnishing the information is required in order to obtain and/or retain benefits (20CFR 702.121). 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.
Form LS-265
Rev. Sept. 2010
DO NOT SEND COMPLETED FORMS TO THIS OFFICE.
Department of Labor, 200 Constitution Avenue, N.W., Room C-4319, Washington, D.C. 20210, and reference the OMB Control Number.
Phone Number
