Form Ca 7B PDF Details

The Leave Buy Back (LBB) Worksheet, captured in the U.S. Department of Labor's CA 7B form, outlines a meticulous process for employees seeking to repurchase leave previously utilized for absences due to work-related injuries. This form serves as a critical document within the Office of Workers' Compensation Programs, detailing the explicit steps and calculations needed for both employees and agencies to navigate the intricate balance between compensation benefits and leave repayment. It specifies how the Weekly Base Payrate, among other earnings additions and the calculated Compensation Rate, influences the potential entitlement from the Federal Employees' Compensation Act (FECA) for the period of leave the employee aims to buy back. The form further divides its structure into sections dedicated to both agency certification and employee claims, thereby ensuring all parties are aligned in terms of expectations and financial responsibilities before proceeding. Instructions spread across the document elucidate the requirements for eligibility, the method for determining compensation, and the implications for retirement and tax considerations, emphasizing the essential coordination between employee decisions and agency records to successfully address the financial dynamics of repurchasing leave.

QuestionAnswer
Form NameForm Ca 7B
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesleave buy back, amount entitlement claimed search, leave lbb online, elects leave claim online

Form Preview Example

Leave Buy Back (LBB) Worksheet/

U.S. Department of Labor

Certification and Election

Office of Workers' Compensation Programs

 

 

Employee Statement - Please carefully read instructions on pages 3 and 4 before filling out this form.

 

 

 

A. Name of Employee: (Last, First, Middle)

 

B. OWCP File Number:

 

 

 

C. Social Security Number:

 

 

 

 

 

D. Period for Which Compensation is Claimed to Repurchase Leave

From:

/

 

/

 

 

 

 

 

 

 

 

To:

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I. Agency Estimate of FECA Entitlement:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A. Weekly Base Payrate (excluding overtime)

 

 

 

 

 

 

 

 

 

 

 

 

 

• Date of Injury

 

 

 

 

 

/

 

 

/

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

• Date Stopped Work

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

 

/

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

• Date of Recurrence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

 

/

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter the greatest amount and the effective date of that amount on line 1.

1 .

 

 

//

B. Additions to Base Pay:

If employee works a regular schedule, state the amount earned weekly. If irregular schedule, state amount earned 1 year prior to date entered on line 1 ÷ by 52.

(effective date)

Night Differential

Sunday Premium

Subsistence/Quarters

Other (Specify)

C.Total Weekly Payrate (Add lines 1 through 5)

D.Compensation Rate (Circle either 2/3 or 3/4)

E.Total Hours Claimed on CA-7a

F.Total Hours Worked per Week

G.Formula (FOR FECA ENTITLEMENT)

$

 

X

 

 

X

 

 

 

 

(Weekly Payrate

(Compensation Rate

 

(Hours

 

See Line 6)

 

See Line 7)

 

See Line 8)

PAGE 1

2.

3.

4.

5.

6.

7.

8.

9.

÷

 

=10. $

 

(Hours Wkd/Wk

See Line 9)

2/3 3/4

Form CA 7b

June 1996

II. Agency Certification:

 

 

H. Total Amount Due Agency to Repurchase Leave

11.

$

 

I. Estimate of FECA Entitlement (SEE LINE 10)

12.

$

J. Balance Due Agency from Employee (LINE H MINUS LINE I)

13. $

 

 

 

I hereby certify that the above is consistent with agency payroll records.

The employing agency agrees to allow the employee to repurchase his/her leave. Leave records will be, or have been, changed from ''Leave with Pay'' to ''Leave without Pay'' for the period shown on the leave analysis.

I further certify that if this claim is signed by the employee, the employee has made arrangements to pay the agency the balance between the total amount the agency requires to recredit leave and the amount of the FECA entitlement.

 

(Signature of Agency Official)

 

(Title/Position)

Phone No

 

Date Signed:

-

Employing Agency Address for Check:

III.Employee Claim:

K.I hereby elect not to repurchase the leave used at this time.

L.I hereby elect FECA compensation to repurchase leave used for medical care or disability resulting from my Job-related injury or condition.

I understand that I am responsible for paying my agency the difference between the FECA entitlement and the amount my agency requires to restore my leave, and have done or made arrangements for this.

I understand that if my actual entitlement to FECA compensation is within 10% of the amount estimated above. OWCP will process the leave buy back. If the payrate used in the worksheet above is within 10% of the payrate determined by FECA, and less than the full period claimed is approved, OWCP will process payment for the approved period.

(Signature of Claimant)

(Date Signed)

PAGE 2

Instructions Form CA-7B

Leave Buy Back Worksheet

This form is intended to accompany Form CA-7, Claim for Compensation, when the employee is claiming leave buy back.

Things to Know About Leave Buy Back:

When an employee uses their sick or annual leave to cover an injury-related absence from work, they may elect to receive compensation instead. Compensation is paid at 2/3 of the employee's base pay if there are no eligible dependents, or at 3/4 with 1 or more dependents. The agency pays leave at 100% of salary. In order for leave to be reinstated, the employee must refund to the agency the difference between the compensation entitlement and the total amount of leave paid by the agency.

The employee's pay status must be changed to LWOP in order for compensation to be paid. Leave is not earned while in LWOP. Also, contributions to the Thrift Savings Plan (TSP) are not made during LWOP. Therefore, the repurchase of leave may result in a reduction in an employee's leave and/or TSP balance. Consult your personnel office to learn how the change to LWOP would effect you.

When a Leave Buy Back (LBB) payment is made during the same year that leave is used, the employee's earnings are reduced by the amount repaid, and tax is not paid for the compensation received. Where leave repurchase is not completed during the same year in which leave is used, the employee may not adjust their prior year tax form. They may only claim the amount of leave paid as an employee expense, if they itemize deductions. Further questions regarding tax implications of LBB should be addressed to the IRS.

A claimant may not repurchase leave used during a period they were eligible for COP.

When disability does not exceed 14 days beyond the COP period, 3 day LWOP must be charged before compensation can be paid. If leave was used for this period, compensation can not be paid for the 3 days, but the claimant will have to pay back leave paid during the 3 days to repurchase the leave.

Instructions to the Employee:

Please submit a claim for a minimum of 10 hours unless no further claim is anticipated. Medical documentation must be provided for all dates claimed.

1.Complete the Form CA-7 for the dates claimed. Where more than one continuous period of leave is claimed, complete Form CA-7a following the instructions for completing that form.

2.Submit the completed CA-7, CA-7a, if appropriate, and medical documentation for all dates claimed, to your agency official. If there are discrepancies, try to reconcile the difference with your agency official prior to submission of the claim.

3.The agency official will provide you with an estimate of worker's compensation benefits due, the total amount owed the agency in order for the leave to be restored, arid the amount you must pay the agency. Using this information, determine whether you wish to repurchase your leave, and check the appropriate block. If you choose to repurchase the leave, you will be required to pay to the agency the difference between the compensation due and the amount owed to the agency.

a.If the total amount of FECA benefits estimated by the agency is not more than 1 0% above the amount determined by OWCP to be accurate, OWCP will process a payment for all hours supported by medical evidence. If medical evidence supports some, but not all of the hours claimed, payment will be made for the approved hours. You may submit a new claim with medical support for the additional hours.

b.If the total amount of FECA benefits estimated by the agency is more than 10% above the correct amount, OWCP will not process the payment. Instead, the Off ice will offer you a new election with the correct amount of FECA benefits payable,

PAGE 3

Instructions to the Agency:

Items A through D (top of form) are self-explanatory.

Section I. Agency Estimate of FECA Entitlement:

Item A: Enter all three pay rate types and effective dates if applicable. Choose the greatest amount of the three and enter the amount and effective date in Line 1. A recurrent pay rate should only be used if:

(1)the employee stops work more than 6 months following their first return to regular, full time duty and

(2)the loss of time is due to disability rather than medical examinations or treatment.

For unusual situations, please refer to Payrate Desk Aid.

Item B: If the employee works a regular schedule, enter the differentials earned weekly. If an irregular schedule, give the total amount earned for the year prior to the date in Line 1 divided by the number of weeks worked in that year.

Please refer to Payrate Desk Aid for guidance on inclusions and exclusions. If in doubt, consult a Claims Examiner.

Item C: Add lines 1 through 5 and enter the total in Line 6.

Item D: Circle the appropriate rate: 2/3 for employees without dependents; 3/4 with dependents.

Dependents include: spouse; children under 18 living with or supported by the employee; children under 23 in school fuil time; children over 18 incapable of self support; and parents wholly supported by the employee.

Item E: Enter the total hours claimed, from Form CA-7a.

Item F: Enter the total hours in the employee's normal work week.

Item G: Formula for FECA Entitlement. Use this formula to calculate estimate of FECA entitlement and enter the result in Line 10.

Example of computation: The weekly pay from line 6 is $574.00. The employee is married, works 40 hours a week, and is claiming 82 hours of leave. FECA entitlement is calculated as follows:

$574.00 x 3/4 x 82 hours ÷ 40 hours = $882.52

Section II. Agency Certification:

Item H & I are self-explanatory. For Line J, subtract Line I from Line H.

Sign and date, and advise the employee of the amount they owe to the agency.

Section III. Employee Claim:

If the employee elects not to repurchase the leave, retain the form in the agency files. If the employee elects to repurchase the leave, submit all claim documents (CA-7, CA-7a & CA-7b) plus any medical documentation to OWCP for processing.

PAGE 4

How to Edit Form Ca 7B Online for Free

When using the online PDF tool by FormsPal, you can complete or edit elects 7 7a form here. To keep our tool on the forefront of practicality, we strive to put into operation user-oriented features and enhancements on a regular basis. We're always thankful for any feedback - assist us with remolding PDF editing. Should you be looking to get going, this is what it will require:

Step 1: First of all, open the pdf editor by pressing the "Get Form Button" above on this page.

Step 2: As soon as you launch the file editor, you'll see the form prepared to be filled out. Besides filling in various blanks, you may as well perform some other actions with the Document, including writing custom words, modifying the original text, inserting graphics, placing your signature to the document, and more.

In order to fill out this PDF form, ensure that you type in the information you need in each and every blank field:

1. When filling out the elects 7 7a form, make sure to complete all essential blanks within the associated section. This will help to hasten the work, allowing for your information to be processed without delay and appropriately.

Learn how to fill out amount entitlement claimed search portion 1

2. Now that this array of fields is complete, it's time to put in the required specifics in If employee works a regular, cid Night Differential, cid Sunday Premium, cid SubsistenceQuarters, cid Other Specify, C Total Weekly Payrate Add lines, D Compensation Rate Circle either, E Total Hours Claimed on CAa, F Total Hours Worked per Week, G Formula for FECA Entitlement, Weekly Payrate Compensation Rate, See Line, See Line, See Line, and Page in order to move forward further.

Simple tips to fill in amount entitlement claimed search portion 2

Always be really mindful when completing D Compensation Rate Circle either and See Line, as this is where a lot of people make mistakes.

3. This 3rd segment is rather simple, II Agency Certification, H Total Amount Due Agency to, I Estimate of FECA Entitlement See, J Balance Due Agency from Employee, I hereby certify that the above is, The employing agency agrees to, I further certify that if this, Signature of Agency Official, TitlePosition, Phone No, and Date Signed - every one of these form fields must be filled out here.

Stage no. 3 for filling in amount entitlement claimed search

4. The subsequent section will require your information in the subsequent areas: Employing Agency Address for Check, III Employee Claim, K I hereby elect not to repurchase, L I hereby elect FECA compensation, my Jobrelated injury or condition, I understand that I am responsible, and I understand that if my actual. Just be sure you enter all required information to go further.

amount entitlement claimed search completion process explained (step 4)

5. To finish your form, the final part requires a few additional blanks. Entering Signature of Claimant, Date Signed, and Page should conclude everything and you can be done in an instant!

Filling in segment 5 of amount entitlement claimed search

Step 3: Immediately after proofreading your form fields you have filled in, click "Done" and you are all set! Join FormsPal today and easily use elects 7 7a form, set for download. Every single modification you make is conveniently preserved , letting you change the form further if needed. FormsPal guarantees your information privacy via a secure method that never saves or distributes any sort of private information provided. Be confident knowing your documents are kept safe any time you use our service!