INSTRUCTIONS FOR FORM CA-1122
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Distribution of the proceeds from the third-party recovery must be made in accordance with 5 U.S.C. 8132.*
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 - PROPERTY DAMAGE - A reasonable amount for 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 an
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). A
reasonable allocation for a spouse's loss of consortium will be up to 25% of Line 3 and for a child or children's loss
of consortium up to 5% per child, to a maximum of 15% for all children of Line 3 (total combined 40%). The
approved allocation must be expressed as a percentage of the amount on Line 3 in the space provided. 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
Line 6 - 20% GUARANTEE - Multiply Line 5 by 20% and enter the result on Line 6. This amount is retained by
you and is not subject to any deductions.
Line 8 - OWCP DISBURSEMENTS - All amounts paid by OWCP (compensation and medical benefits, but not
continuation of pay (COP)) less the gross amount of any prior refunds made (from Line 7 on any earlier EN-1122
or CA-1122) are to be entered in the space provided.
Line 9 - REFUND TO OWCP - Compare Line 7 with Line 8 (refundable disbursements), and enter the lower of
the two on Line 9. This is the amount to be refunded to OWCP. NOTE: You must contact OWCP to obtain a
current history of the disbursements made to you and your medical providers for compensation and medical
benefits.
Line 10 - CREDIT AGAINST FUTURE BENEFITS (SURPLUS) - If Line 7 is less than Line 8 (Refundable
Disbursements), there is no credit to be applied against future benefits. If Line 7 is greater than Line 8, a credit
against future benefits must be applied and is determined by subtracting Line 8 from Line 7. The surplus is
retained by you and is the amount against which OWCP will credit future compensation payable on account of the
same injury. Because you will not be entitled to any further payments from OWCP until you are eligible for
additional compensation in an amount greater than the surplus, you should submit all medical bills you have paid
for the injury to OWCP, regardless of when you paid them. You will not be reimbursed for these payments, but the
amount you paid will be used to reduce the amount of the surplus.
The refund check for the amount shown in Line 9 should be made payable to the "U.S. 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
200 Constitution Avenue NW
Room S4325
Washington, DC 20210.
CA-1122 PAGE 4 (Rev. 05-15)
