UNITED STATES DEPARTMENT OF LABOR EMPLOYMENT STANDARDS ADMINISTRATION OFFICE OF WORKERS' COMPENSATION PROGRAMS

STATEMENT OF RECOVERY

Claimant:		File Number:
Date of Injury/Death:		Employing Agency:

 

(1)	Gross recovery
(2)	Less Property Damage
(3)	Balance
(4)	Less Attorney's Fee (Fee is ________ % of line 3)
(5)	Balance
(6)	Less Court Costs (must be itemized)
(7)	Balance (adjusted gross recover)
(8)	Less 1/5 (20% of line 7)
(9)	Balance
(10)	Less Payment to Public Health Service
(11)	Balance
(12)	Less Medical Expenses Paid by Claimant
(13)	Balance
(14)	OWCP Disbursements (including compensation and medical but excluding COP) or line 13, whichever is less
(15)	Less Government Allowance for Attorney's Fee (retained by claimant)
(16)	Refund
(17)	Surplus (line 13 less line 14)

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