Form Owcp 20 – Fill Out and Use This PDF

The OWCP-20 form is a crucial document from the U.S. Department of Labor's Office of Workers' Compensation Programs designed for the process of overpayment recovery. It serves as a questionnaire for individuals who have received excess payments to declare possession of overpayment, potential financial hardship due to refund, and other pertinent details. Anyone facing overpayment issues should complete the relevant sections—Parts I, II, and V, with additional parts required under specific circumstances. For guidance on filling out the form correctly and to avoid any potential legal complications, click the button below.

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Form Owcp 20 PDF Details

Dealing with the aftermath of receiving an overpayment from the Office of Workers' Compensation Programs (OWCP) can be daunting, and the OWCP-20 form is a critical tool in this process. Specifically designed by the U.S. Department of Labor, this questionnaire assists in the recovery of overpayments made to employees under various compensation programs including but not limited to the Federal Employees' Compensation Act (FECA), the Black Lung Benefits Act (BLBA), and the Energy Employees Occupational Illness Compensation Program Act (EEOICPA). The form is divided into several parts, each tailored to gather detailed information about the recipient's current financial situation, their understanding and handling of the overpayment, and whether repaying it would cause undue hardship. Sections include inquiries about possession of overpayment, monthly income and expenses, property ownership, and an explanation section for those claiming the overpayment was not their fault. Additionally, it addresses situations where a representative payee is involved. Completion of this form is voluntary but failing to do so may result in the denial of a waiver for overpayment recovery, underscoring the importance of providing accurate and comprehensive details. This form not only serves as a means for the Department of Labor to assess the extent of overpayment recovery but also offers an opportunity for those overpaid to explain their circumstances, potentially easing the financial burden of repayment.

Question	Answer
Form Name	Form Owcp 20
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	owcp 20, what does 48r mean, owcp 20 form, owcp ca 20

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Overpayment Recovery	U.S. Department of Labor
Questionnaire	Office of Workers’ Compensation Programs

Overpaid Person - Last Name	First Name	MI
Claimant - Last Name	First Name	MI

Claim No.

OMB No.: 1240-0051 Expires: 04-30-2019

EVERYONE MUST COMPLETE PART I, PART II, AND PART V,		PART III
EVERYONE MUST COMPLETE PART I, PART II, AND PART V,		PART III
COMPLETE THE FOLLOWING PARTS ONLY IF MARKED:

PART IV

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

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?		Yes
		Yes
If "Yes", explain:

Revised July 2012	OWCP-20 (Rev. 07-12)
Previous editions unusable

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	$0.00

4. Do you support, either fully or in part, anyone other than yourself?		Yes

If "Yes", give the following information about each person you support:

Name

Address

Age

Relationship To You (If None, Enter "None")

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 expenses (Such as: Miscellaneous household expenses, medical and dental care (not		$
covered by insurance), automobile expenses or other transportation costs, personal necessities.)		$


Other Debts Being Paid By Monthly Installments

Creditor	Amount Owed	Monthly Payment

	$	$

	$	$

	Total Monthly Expenses	$0.00

Revised July 2012	OWCP-20 Page 2 (Rev. 07-12)
Previous editions unusable

6. Not counting your home, family automobile, or household furnishings,	Yes	No

do you or your spouse own any valuable property or real estate?

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	$0.00

f. Name of stocks and bonds you have (use separate sheet if	g. Name and address of financial institutions(s)
space is insufficient).

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?

Yes

There was no change

If "Yes", when did you report? (Give date):

If "No", why didn't you report?

Revised July 2012	OWCP-20 Page 3 (Rev. 07-12)
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:

13. Were the incorrect payments used for this person?	Yes	No

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)

City

Zip

County (if any) in which you now live:

Revised July 2012	OWCP-20 Page 4 (Rev. 07-12)
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.

Revised July 2012	OWCP-20 Page 5 (Rev. 07-12)
Previous editions unusable

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Form Owcp 20 – Fill Out and Use This PDF

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