Fill - Free fillable U.S. DEPARTMENT OF LABOR OMB No. 1240-0001 Expiration (Department of Labor) PDF form

U.S. DEPARTMENT OF LABOR

Office of Workers’ Compensation Programs

Division of Federal Employees’ Compensation

OMB No. 1240-0001

Expiration Date: 02-28-2022

File Number: Employee:

LONG FORM STATEMENT OF RECOVERY

(See following pages for instructions)

1. Gross Recovery (Entire Amount of the Award).............................................1. $

2. Amount of Real or Personal Property Damage (Must be approved)...................2.

3. Subtotal A (Line 1 minus Line 2)......................................................................3.

4. Amount Allocated for Loss of Consortium ( % of Line 3).......................4.

5. Subtotal B (Line 3 minus Line 4)......................................................................5.

6. Amount Allocated for Wrongful Death* ( % of Line 5)............................6.

7. Amount Allocated for Survival Action* ( % of Line 5).............................7.

8. Subtotal C (for Wrongful Death enter Line 6; for a

Survival Action 8. enter Line 7; if neither enter Line 5)....................................8.

9. Attorney’s Fees (Fees must be reduced by the percentage(s) entered on

Lines 4, 6, or 7)** SEE INSTRUCTIONS BEGINNING ON PAGE 4.

Enter the percentage charged by the attorney here: %

Enter the actual fees paid to the attorney here: $ ....9.

10. Subtotal D (Line 8 minus Line 9)...................................................................10.

11. Costs of suit or settlement (Costs must be reduced by the percentage

entered on Lines 4, 6, or 7)** SEE INSTRUCTIONS BEGINNING PAGE 5.

Enter total costs here: $ ..............................................11.

12. Subtotal E (Line 10 minus Line 11)..............................................................12.

13. 20% of Subtotal E (Line 12 x .20)**..............................................................13.

14. Subtotal F (Line 12 minus Line 13)...............................................................14.

15. Refundable Disbursements..........................................................................15.

16. Subtotal G (Lower of Line 14 or Refundable Disbursements)......................16.

17. Government’s Allowance for Attorney’s Fees (% on Line 9 x Line 16) (This

amount does not include a reduction for costs)***........................................17.

18. Refund to be paid to the United States (Line 16 minus Line 17).............18.

19. Credit Against Future Benefits (Surplus) (If Line 14 is greater than Line 15,

then Line 14 minus Line 15, otherwise enter “0”)**.......................................19.

* NOTE: If the recovery was from both a Wrongful Death action and a Survival action, a separate

CA-1108 must be prepared for each cause of action.

** The regulations require attorney’s fees and costs to be reduced by the percentage(s) of the gross

recovery allocated for loss of consortium, wrongful death and/or survival on Lines 4, 6, or 7.

*** Pursuant to the statute, “the beneficiary is entitled to retain, as a minimum, at least one-fifth of the

net amount of the money or other property remaining after the expenses of a suit or settlement

have been deducted; and in addition to this minimum and at the time of distribution, an amount

equivalent to a reasonable attorney’s fee proportionate to the refund to the United States.” This is

captured in Lines 13 and 17.

CA-1108 (Rev. 02-19)

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CERTIFICATION

I understand that anyone who fraudulently conceals or fails to report information that would have an effect on any

benefits, or who makes a false statement or misrepresentation of a material fact in claiming a payment or benefit

under the Federal Employees’ Compensation Act may be subject to criminal prosecution, from which a fine and/or

imprisonment may result.

I certify that the above statements made on this Form CA-1108 are true, complete and correct to the best of my

knowledge and belief. I also certify that the information on this form does/does not (circle one) represent my

settlement with all defendants in the case, and that I have/do not have (circle one) other cases or claims

pending or unresolved against any other third parties liable for the same injuries for which FECA benefits have

been paid or are payable.

Signature of Beneficiary or Authorized Representative

Date

Print Name

(This space for use by the U.S. Department of Labor only)

Approved: Date:

WARNING

A FALSE OR EVASIVE ENTRY ON FORM CA-1108, OR THE OMISSION OF AN ENTRY ON THE FORM, MAY

SUBJECT YOU TO CIVIL LIABILITY. A FRAUDULENT ENTRY MAY RESULT IN CRIMINAL PROSECUTION.

ALL ENTRIES ON FORM CA-1108 ARE SUBJECT TO INVESTIGATION FOR VERIFICATION.

CA-1108 PAGE 2 (Rev. 02-19)

PRIVACY ACT STATEMENT

The following statement is made in accordance with the Privacy Act of 1974 (5. U. S. C. 552a). The authority for

requesting the information is the Federal Employees’ Compensation Act (5 U. S. C. 8101 et seq.). Information

collected will be handled and stored in compliance with the Freedom of Information Act and the Privacy Act of

1974, as amended (5 U.S.C. 552a). The information will be used to determine the amount of refund due to the

United States out of the proceeds of a third party action. Failure to furnish the requested information will result in a

delay in processing the third party recovery. In addition to those Department-wide routine uses set forth above in

the General Prefatory Statement to this document, disclosure of information from this system of records may be

made to the following individuals and entities for the purposes noted when the purpose of the disclosure is both

relevant and necessary and is compatible with the purpose for which the information was collected: to any attorney

or other representative of a FECA beneficiary for the purpose of assisting in a claim or litigation against a third

party or parties potentially liable to pay damages as a result of the FECA beneficiary's FECA-covered injury and

for the purpose of administering the provisions of sections 8131-8132 of the FECA. Any such third party, or a

representative acting on that third party's behalf, may be provided information or documents concerning the

existence of a record and the amount and nature of compensation paid to or on behalf of the FECA beneficiary for

the purpose of assisting in the resolution of the claim or litigation against that party or administering the provisions

of sections 8131-8132 of the FECA. DOL/GOVT-1 (Office of Workers' Compensation Programs, Federal

Employees' Compensation Act File) 67 F.R. 16827, 4/8/02.

PUBLIC BURDEN STATEMENT

We estimate that it will take an average of 30 minutes to respond to this collection of information, which includes

time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and

completing and reviewing the collection of information. A respondent’s obligation to respond is required in

accordance with 5 U. S. C. 8131-8132 of the FECA to obtain or retain benefits. 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 U.S. Department of Labor, OWCP, Room S-3229, 200 Constitution Avenue, NW,

Washington, DC 20210 and reference the OMB control number. DO NOT SEND THE COMPLETED FORM TO

THIS ADDRESS. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a

collection of the information unless such collection displays a valid OMB control number.

CA-1108 PAGE 3 (Rev. 02-19)

NOTICE

If you have a disability (a substantially limiting physical or mental impairment), please contact our office/claims

examiner for information about the kinds of help available such as communication assistance (alternate formats or

sign language interpretation), accommodations and modifications.

INSTRUCTIONS FOR FORM CA-1108

*Distribution of the proceeds from the third-party recovery must be made in accordance with 5 U.S.C. 8132.*

Using the form’s automatic calculations will help to avoid error.

Line 1- GROSS RECOVERY – The entire amount of any award received as a result of a judgment entered in a

lawsuit, settlement of a lawsuit, or any other settlement or recovery from a responsible third party, must be entered

on Line 1 as the gross recovery.

Line 2 - REAL OR PERSONAL PROPERTY DAMAGE – A reasonable amount for real or personal property, such as

clothing or other personal belongings that are damaged or destroyed in an accident may be deducted. These

amounts must be itemized. If an automobile or other vehicle is damaged or destroyed, furnish the year, make and

model, and the Blue Book value of the vehicle, along with your insurance company’s estimate of the damage

declaring the vehicle to be a total loss. A copy of the repair bill will suffice if the vehicle was not totally destroyed.

Line 4 - LOSS OF CONSORTIUM – OWCP or SOL (or whoever else has been delegated the authority) will determine

a reasonable allocation of the judgment or settlement for loss of consortium, unless the judgment is from a contested

verdict, then those allocations will be used. The amount allocated for loss of consortium must be a percentage of the

amount on Line 3, and must be approved by OWCP or SOL (or other delegated authority). In a non-death case or a

death case where no cause of action for wrongful death is asserted, a reasonable allocation for a spouse’s loss of

consortium will be up to 25% of Line 3; a reasonable allocation for a child or children’s loss of consortium, where no

cause of action for wrongful death is asserted, will be up to 5% of Line 3 per child, to a maximum for all children of

15% of Line 3 (total combined 40%). In a death case alleging wrongful death, a reasonable allocation for a spouse’s

loss of consortium will be up to 15% of Line 3 and for a child or children’s loss of consortium up to 5% per child, to a

maximum of 10% for all children (total combined 25%). In cases where loss of consortium has been asserted for both

a spouse and a child or children, multiply the total allowable percentages by Line 3. The beneficiary must establish

that loss of consortium was asserted in the suit or claim and that loss of consortium claims are permitted under the

state law where the action was brought. FECA beneficiaries may accept the determination of the percentage allocated

or demonstrate good cause in writing for a different percentage to be allocated for loss of consortium. In any case

where a percentage of the gross recovery has been allocated to a loss of consortium claim, the attorney’s fees and

court costs will automatically be reduced by the same percentage. These calculations must be done in consecutive

order, line-by-line, to calculate the reductions and the refund due correctly. See instructions below for attorney’s fees

and court costs.

Lines 6 & 7 - WRONGFUL DEATH OR SURVIVAL – Amounts received, where both wrongful death and survival

actions have been asserted, must be allocated between the two actions, and separate CA-1108s must be filed for

each cause of action. OWCP or SOL will determine a reasonable allocation of the judgment or settlement for the

wrongful death action and the survival action, unless the judgment is from a contested verdict, then those

percentages will be used. The amount allocated for wrongful death and survival must be a percentage of the amount

on Line 5 and must be approved by OWCP or SOL. For a wrongful death action, a reasonable allocation is 65% of the

amount on Line 5. For a survival action, a reasonable allocation is 35% of the amount on Line 5. FECA beneficiaries

may accept the determination of the percentage allocated or demonstrate good cause in writing for different

percentages to be allocated for wrongful death and survival. In any case where a percentage of the gross recovery

has been allocated to a loss of consortium claim, wrongful death claim, and/or survival claim, the attorney’s fees and

court costs will automatically be reduced by the same percentage(s). These calculations must be done in consecutive

order, line-by-line, to calculate the reductions and the refund due correctly. See instructions below for attorney’s fees

and court costs.

Line 9 - ATTORNEY'S FEES – Reasonable attorney’s fees actually paid, up to a maximum of 40% of the gross

recovery, may be deducted from Subtotal C. OWCP or SOL (or whoever else has been delegated the authority)

determines whether a fee is reasonable. The fee will be calculated automatically when the attorney’s fee percentage

is entered in the designated space on Line 9. If a percentage is not entered but the amount of the fees paid is

entered, the percentage will be calculated automatically by dividing the amount of the total fee charged by the amount

of the gross recovery on Line 1 (total fee divided by gross recovery). The amount automatically entered on Line 9 will

be calculated by multiplying Line 8 (Subtotal C) by the attorney’s fees percentage. Using the form’s automatic

calculations will help to avoid errors.

Attorney’s fees will be reduced by the percentage(s) entered on this form for loss of consortium, wrongful death, and/

or survival. If loss of consortium is claimed, the total attorney’s fees will be multiplied by the percentage entered on

Line 4, and the result will be subtracted from the total attorney’s fees. Then, the remaining amount will be entered

automatically on Line 9. For example, if the total attorney’s fees are $48,000 and the allocation for loss of consortium

is 25%, the calculation would be $48,000 − ($48,000 x 25%) = $36,000. Thus, $36,000.00 will be entered

automatically on Line 9.

CA-1108 PAGE 4 (Rev. 02-19)

CA-1108 PAGE 5 (Rev. 02-19)

If wrongful death is asserted but there is no claim for loss of consortium, the total attorney’s fees will be multiplied by

the percentage entered on Line 6, and the result will be entered automatically on Line 9. If a survival claim is

asserted but there is no claim for loss of consortium, the total attorney’s fees will be multiplied by the percentage

entered on Line 7, and the result will be entered automatically on Line 9. For example, if attorney’s fees are $48,000

and 65% is entered on Line 6 of the wrongful death CA-1108, the calculation would be $48,000 x 65% = $31,200;

then, $31,200 would be entered automatically on Line 9. If attorney’s fees are $48,000 and 35% is entered on Line 7

of the survival CA-1108, the calculation would be $48,000 x 35% = $16,800; then $16,800 would be entered

automatically on Line 9.

If wrongful death or survival actions are asserted in addition to loss of consortium, first, the attorney’s fees will be

reduced for loss of consortium. Next, the result will be multiplied by the percentage entered on either Line 6 for the

wrongful death CA-1108 or Line 7 for the survival CA-1108, and that result will be entered automatically on Line 9.

For example, if the total attorney’s fees are $48,000, 25% is allocated for loss of consortium, and 65% for wrongful

death, first, the total attorney’s fees would be reduced by 25% for loss of consortium, and then 65% of that amount

would be entered automatically on Line 9. The calculations performed automatically would be $48,000 – ($48,000 x

25%) = $36,000.00; next ($36,000 x 65%) = $23,400; and $23,400 would be entered automatically on Line 9 of the

wrongful death CA-1108. If attorney’s fees are $48,000, 25% is allocated for loss of consortium and 35% for the

survival action, the calculations performed automatically would be $48,000 – ($48,000 x 25%) = $36,000.00; next

($36,000 x 35%) = $12,600; and $12,600 would be entered automatically on Line 9 of the survival CA-1108.

Line 11 - COURT COSTS - These consist of items such as filing fees, witness fees, actual out-of-pocket costs of the

suit or settlement or any payments for expert testimony. They do not include items such as payments for overhead or

medical treatment. COSTS OF SUIT OR SETTLEMENT MUST BE ITEMIZED AND APPROVED BY OWCP OR SOL

(OR WHOEVER ELSE HAS BEEN DELEGATED THE AUTHORITY. The form will automatically calculate costs.

Costs will be reduced by the percentage(s) entered on this form for loss of consortium, wrongful death, or survival. If

loss of consortium is claimed, the total court costs will be multiplied by the percentage entered on Line 4, and the

result will be subtracted from the total court costs. Then, the remaining amount will be entered automatically on Line

11. For example, if the total court costs are $48,000 and the allocation for loss of consortium is 25%, the calculation

would be $48,000 − ($48,000 x 25%) = $36,000.

If wrongful death is asserted but there is no claim for loss of consortium, the total court costs will be multiplied by the

percentage entered on Line 6 and the result will be entered automatically on Line 11. If a survival claim is asserted

but there is no claim for loss of consortium, the total court costs will be multiplied by the percentage entered on Line

7, and the result will be entered automatically on Line 11. For example, if court costs are $48,000 and 65% is entered

on Line 6 of the wrongful death CA-1108, the calculation would be $48,000 x 65% = $31,200; then, $31,200 would be

entered automatically on Line 11. If court costs are $48,000 and 35% is entered on Line 7 of the survival CA-1108,

the calculation would be $48,000 x 35% = $16,800; then $16,800 would be entered automatically on Line 11.

If wrongful death or survival actions are asserted in addition to loss of consortium, first, the costs will be reduced for

loss of consortium. Next, the result will be multiplied by the percentage entered on either Line 6 for the wrongful

death CA-1108 or Line 7 for the survival CA-1108, and that result will be entered automatically on Line 11. For

example, if the total court costs are $48,000, 25% is allocated for loss of consortium, and 65% for wrongful death,

first, the total costs would be reduced by 25% for loss of consortium, and then 65% of that amount would be entered

automatically on Line 11. The calculations performed automatically would be $48,000 – ($48,000 x 25%) =

$36,000.00; next ($36,000 x 65%) = $23,400; and $23,400 would be entered automatically on Line 11 of the wrongful

death CA-1108. If court costs are $48,000, 25% is allocated for loss of consortium and 35% for the survival action,

the calculations performed automatically would be $48,000 – ($48,000 x 25%) = $36,000.00; next ($36,000 x 35%) =

$12,600; and $12,600 would be entered automatically on Line 11 of the survival CA-1108.

Line 13 - 20% GUARANTEE – Multiply Subtotal E by 20% (.20). This amount is turned over to the claimant and is

not subject to any deductions.

Line 15 - REFUNDABLE DISBURSEMENTS – Enter all amounts paid by OWCP (for compensation and medical

benefits but not Continuation of Pay), less any amounts of refundable disbursements listed on any prior Forms

EN-1108 or CA-1108, in the space provided.

Line 16 - SUBTOTAL G – Compare Subtotal F (Line 14) with the refundable disbursements (Line 15), and enter the

lower of the two on Line 16. The lower amount is Subtotal G.

CA-1108 PAGE 6 (Rev. 02-19)

Line 17 - GOVERNMENT ALLOWANCE FOR ATTORNEY'S FEES – The Government contributes a portion of its

refund to the claimant toward payment of attorney’s fees. This is computed by multiplying Subtotal G (Line 16) by the

attorney’s fees percentage entered on Line 9.

Line 18 - REFUND AMOUNT – (Line 16 minus Line 17) - This balance is the amount to be refunded to the

Government for OWCP disbursements.

Line 19 - CREDIT AGAINST FUTURE BENEFITS (SURPLUS) – If Subtotal F (Line 14) is less than the Refundable

Disbursements (Line 15), there is no credit to be applied against future benefits. If Subtotal F (Line 14) is greater than

the refundable disbursements (Line 15), a credit against future benefits must be applied and is determined by

subtracting the refundable disbursements (Line 15) from Subtotal F (Line 14).The surplus is retained by the claimant

and is the amount against which OWCP will credit future compensation, including wage loss compensation, schedule

award benefits and medical expenses, on account of the same injury. OWCP will resume payment of compensation

only after the awarded compensation exceeds the amount of the surplus. For this reason, all medical bills related to

the injury that the claimant pays should be submitted to OWCP, regardless of when payment was made. The

claimant will not be reimbursed for these payments, but the amounts paid will be used to reduce the amount of the

surplus.

The refund check for the amount shown in Line 18 should be made payable to the "United States Department of

Labor, OWCP”. PLEASE INCLUDE THE OWCP FILE NUMBER ON THE CHECK.

Unless directed otherwise, send refund check to:

U.S. Department of Labor

Office of the Solicitor

Division of Federal Employees’ and Energy Workers’ Compensation

200 Constitution Avenue NW, Room S4325

Washington, DC 20210

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