Fillable Overpayment Recovery Questionnaire U.S. Department of Labor Claimant (Department of Labor)

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Overpayment Recovery Questionnaire U.S. Department of Labor Claimant (Department of Labor)

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Overpayment Recovery
Questionnaire
U.S. Department of Labor
Office of Workers’ Compensation Programs
Overpaid Person - Last Name
Claim No.
EVERYONE MUST COMPLETE PART I, PART II, AND PART V,
COMPLETE THE FOLLOWING PARTS ONLY IF MARKED:
PART III PART IV
OMB No.: 1240-0051
Expires: 07/31/2022
Part I - Possession of Overpayment (to be completed by all applicants for waiver)
1. Do you have any of the incorrectly paid checks or payments in your possession?
Yes No
If “Yes”, show the total amount: $_____________________. (These funds should be returned to the U.S. Department of Labor immediately).
2. Since you were notified of the overpayment, have you transferred by loan, gift, sale, etc. any property or cash?
If "Yes", explain:
Yes No
First Name
MI
First Name
Claimant - Last Name
MI
Revised July 2012
Previous editions unusable OWCP-20 (Rev. 07-12)
Reset
Print
Part II - REFUND QUESTIONNAIRE
(To be completed by the person for whom repayment of the overpayment would cause undue hardship)
3. List your monthly income (Including any income of your spouse or any dependent
relative living in the household with you) from:
Monthly Income
Social Security Benefits
Supplemental Security Income Payment
State or Local Welfare Payment. Specify:
Other benefits, such as Veterans Administration, Civil Service, Unemployment, Black Lung, FECA,
Railroad, Private Pension, etc. Specify:
Earnings (take-home wages and average net earnings from self-employment). Specify:
Other income, such as dividends, interest, rentals, roomers or boarders, etc. Specify:
Total Monthly income
4. Do you support, either fully or in part, anyone other than yourself?
If "Yes", give the following information about each person you support:
Yes No
Name Address Age
Relationship To You
(If None, Enter "None")
OWCP-20 Page 2 (Rev. 07-12)
Revised July 2012
Previous editions unusable
5. List the usual expenses of your household on a monthly basis
Monthly Payment
Rent or Mortgage, including Property Tax
Food
Clothing
Utilities (electricity, gas, fuel, telephone, water)
Other Debts Being Paid By Monthly Installments
Creditor Amount Owed
Monthly Payment
$
$
Other expenses (Such as: Miscellaneous household expenses, medical and dental care (not
covered by insurance), automobile expenses or other transportation costs, personal necessities.)
Total Monthly Expenses
$
$
$
$
$
$
$
$
$
$
$
$
$
6. Not counting your home, family automobile, or household furnishings,
do you or your spouse own any valuable property or real estate?
OWCP-20 Page 3 (Rev. 07-12)
Revised July 2012
Previous editions unusable
Yes No
If "Yes", specify and give current market value. If mortgage, show amount of mortgage.
7. List below any funds you have (including those of your spouse, if you live with your spouse):
a. Cash on hand
b. Checking account balance
c. Savings account balance
d. Current value of any stocks and bonds
e. Value of other personal property and other funds
TOTAL
f. Name of stocks and bonds you have (use separate sheet if
space is insufficient).
g. Name and address of financial institutions(s)
PART III - WITHOUT FAULT STATEMENT
8. Explain fully why you thought the incorrect payment was due to you and why the overpayment was not your fault:
9. Did you report the change in circumstances which affected your monthly payment?
If "Yes", when did you report? (Give date):
Yes No
There was no change
If "No", why didn't you report?
$
$
$
$
$
OWCP-20 Page 4 (Rev. 07-12)
Revised July 2012
Previous editions unusable
10. When were the conditions under which you could receive payments first explained to you?
11. Do you NOW fully understand reporting responsibilities?
Yes No
If "No", explain:
PART IV - REPRESENTATIVE PAYMENT MADE
(to be completed ONLY by a representative payee)
12. Give the name and present address of the person for whom you received payment:
Yes No
13. Were the incorrect payments used for this person?
Explain:
PART V
14. Remarks (optional):
I know that anyone who makes or causes to be made a false statement or representation of material fact in an application or for use in
determining a right to payment under the BLBA, EEOICPA and FECA commits a crime punishable under Federal and/or State law. I affirm
that all information I have given in this document is true.
(Signature of Overpaid Person or Representative Payee) (Date - Month, day, year)
(Telephone Number)
Mailing Address (Number and Street, Apt. No., P.O. Box, Rural Route)
State
City
Zip
County (if any) in which you now live:
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.
Accommodation Statement
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.
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Overpayment Recovery Questionnaire U.S. Department of Labor Claimant (Department of Labor)

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Completed 26 January 2021

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