Dol-Owcp Forms - Postal Reporter
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U.S. Department of Labor
Claim for Compensation
Office of Workers' Compensation Programs
SECTION 1
EMPLOYEE PORTION
a. Name of Employee
Last
First
Middle
OMB No. 1240-0046
Expires: 10-31-2014
b. Mailing Address ( Including City State, ZIP Code )
c. OWCP File Number
d. Date of Injury
e. Social Security Number
Month Day Year
E-Mail Address (Optional)
f. Telephone No./FAX No.
SECTION 2
Compensation is claimed for:
Inclusive Date Range
From
Intermittent?
To
a.
Leave without pay
Yes
No
Go to Section 3
b.
Leave buy back
Yes
No
Go to Section 3, and Complete Form CA-7b
c.
Other wage loss; specify type,
Yes
No
Go to Section 3
such as downgrade, loss of
Type:
night differential, etc.
If intermittent, complete Form CA-7a,
Time Analysis Sheet
d.
Schedule Award (Go to Section 4)
SECTION 3
You must report all earnings from employment ( outside your federal job); include any employment for which you received a salary, wages,
income, sales commissions, piecework, or payment of any kind during the period(s) claimed in Section 2. Include self-employment, involvement in
business enterprises, as well as service with the military forces. Fraudulent concealment of employment or failure to report income may result in forfeiture of
Have you worked outside your federal job for the period(s) claimed in Section 2
compensation benefits and/or criminal prosecution.
?
Name and Address of Business:
Yes
Name
Address
City
State
ZIP Code
No
Go to
section 4
Dates Worked:
Type of Work:
Is this the first CA-7 claim for compensation you have filed for this injury?
SECTION 4
Yes
Complete Sections 5 through 7 and a Form SF-1199A, "Direct Deposit Sign-up"
Has there been any change in your dependents, or has your direct deposit information changed, or has there been a claim
No
filed with U.S. Civil Service Retirement, another federal retirement or disability law, or with the Department of Veterans
Affairs since your last CA-7 claim?
Yes
- Complete Sections 5 through 7 or a new SF-1199A to reflect change(s)
No -
Complete Section 7
SECTION 5 List your dependents ( including spouse ):
Living with you?
Name
Social Security #
Date of Birth
Relationship
Yes No
Just A Hacker
000-00-0000
11/10/1964
husband
Just A Hacker, Jr
000-00-0001
11/10/1984
son
For dependents not living
with you complete items
Justin A Hacker
000-00-0002
11/10/1986
daughter
a and b below. ,
a. Are you making support payments for a dependent shown above?
Yes
No
If Yes, support payments are made to:
Name
ZIP Code
Address
City
State
b. Were support payments ordered by a court?
Yes
No
If Yes, attach copy of court order.
a. Was/Will there be a claim made against a 3rd party?
Yes
No
SECTION 6
b. Have you ever applied for or received disability benefits from the Department of Veterans Affairs?
Yes
Full Address of VA Office Where Claim Filed
Nature of Disability and Monthly Payment
Claim Number
No
c. Have you applied for or received payment under any Federal Retirement or Disability law?
Yes
Claim Number
Date Annuity Began
Amount of Monthly Payment
Retirement System (CSRS, FERS, SSA, Other)
CSRS
FERS
SSA
Other
No
SECTION 7 I hereby make claim for compensation because of the injury sustained by me while in the performance of my duty for the United
States. I certify that the information provided above is true and accurate to the best of my knowledge and belief.
Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud, to obtain
compensation as provided by the FECA, or who knowingly accepts compensation to which that person is not entitled is subject to civil or
administrative remedies as well as felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or
imprisonment, or both. In addition, a felony conviction will result in termination of all current and future FECA benefits.
Employee's Signature
Date ( Mo., day, year)
CA-7 (Rev. 05-11)
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