Rehabilitation Maintenance Certificate
U.S. Department of Labor
Office of Workers' Compensation Programs
IMPORTANT: No monies or benefits can be paid under this program unless this report is completed and filed as requested by
law (5 U.S.C. 8111;33 U.S.C. 901 as extended and amended). The information collected will be handled and stored in
compliance with the Freedom of Information Act, Privacy Act of 1974 and OMB Cir. No. 130.
If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation),
accommodations and/or modifications, please contact OWCP. See additional guidance below for REQUESTS FOR
ACCOMMODATIONS OR AUXILIARY AIDS AND SERVICES.
OMB No.1240-0012
Expires: 02-28-2022
1. Name of Injured Worker (First, Middle Initial, Last) 2. OWCP No.
3. Complete Mailing Address (No., Street, City, State, ZIP Code)
Address Line 1
Address Line 2
City State ZIP
4. Maintenance Payment Per Week
$
5. Maintenance Pay Period (Month, Day, Year)
From Thru
Federal Employees' Compensation Act
Longshore and Harbor Workers' Compensation Act
6. Appropriate Act (Mark X)
INJURED WORKER
PLEASE READ CAREFULLY - Submit this form to the Rehabilitation Counselor assigned to your case by OWCP. Complete items 7
thru 9, typing, or printing clearly with a ball point pen; then sign your name legibly in item 10. Next have an official at your facility certify
your statement by completing items 11 thru 13.
7. Weekly Training Schedule
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Other
8. Days Absent From Program (Month, Day, Year) 9. Reason For Absence(s)
10. INJURED WORKER: I certify that I participated in my rehabilitation program, as prescribed by the Office of Workers'
Compensation Programs, and hereby request a maintenance payment for the above period.
Signature
Date Signed
11. Name
12. Title
13. FACILITY OFFICIAL: I certify that the above statement in item 8 is true.
Signature
Date Signed
14. REMARKS:
15. Amount Approved
16. District Office No.
FACILITY
OFFICIAL
OWCP REHABILITATION SPECIALIST
OR REHABILITATION COUNSELOR
17. OWCP REHABILITATION SPECIALIST or REHABILITATION COUNSELOR:
I recommend the amount approved be paid to the injured worker.
Signature
Date Signed
Print Name
REQUESTS FOR ACCOMMODATIONS OR AUXILIARY AIDS AND SERVICES
IF YOU HAVE A DISABILITY, FEDERAL LAW GIVES YOU THE RIGHT TO RECEIVE HELP FROM THE OWCP IN THE FORM OF
COMMUNICATION ASSISTANCE, ACCOMMODATION(S) AND/OR MODIFICATION(S) TO AID YOU IN THE OWCP 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 ACCOMMODATE YOUR DISABILITY.
PLEASE CONTACT OUR OFFICE OR YOUR OWCP CLAIMS EXAMINER TO ASK ABOUT THIS ASSISTANCE.
OWCP-17 (Rev. 02-19)
FOR OWCP USE ONLY
Previous editions usable
