OWCP-20 Page 5 (Rev. 07-12)
Revised July 2012
Previous editions unusable
Privacy Act Statement
Collection of this information by OWCP is authorized by section 8129(b) of the Federal Employees'
Compensation Act (5 USC 8129(b)), section 413(b) of the Black Lung Benefits Act (30 USC 923(b)) and
section 7385j-2 of the Energy Employees Occupational Illness Compensation Program Act (42 USC
7385j-2). The information provided will be used to determine the extent to which overpayments of
benefits will be recovered and is fully protected by the Privacy Act of 1974, as amended (5 USC 552a)
under the following systems of records: DOL/GOVT-1, DOL/ESA-6 and DOL/ESA-49, published in the
Federal Register , Vol. 67, page 16816, April 8, 2002, or as updated and republished. This information
may be disclosed to private collection agencies under contract with the Departments of Labor, Justice or
Treasury, or to the Department of Justice for litigation purposes. Additional disclosures may be made
through the routine uses for information contained in the referenced systems of records.
Public Burden Statement
Under the Paperwork Reduction Act, persons are not required to respond to a collection of information
unless such collection displays a valid OMB control number. Completion and submission of this form is
voluntary; however, failure to provide the information may result in the denial of a request to waive
recovery of the overpayment. We estimate that it will take an average of 60 minutes to complete this
collection of information, including time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information.
If you have any comments regarding this estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, send them to the Direct or , U.S. Department of Labor,
Office of Workers’ Compensation Programs, Room S- 3524, 200 Constitution Avenue NW, Washington,
DC 20210. DO NOT SEND THE COMPLETED FORM TO THIS ADDRESS.
If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law
gives you the right to receive help from OWCP in the form of communication assistance, accommodation
and modification to aid you in the claims process. For example, we will provide you with copies of
documents in alternate formats, communication services such as sign language interpretation, or other
kinds of adjustments or changes to account for the limitations of your disability. Please contact our office
or your claims examiner to ask about this assistance.