LS-200 proposed Report of Earnings

Report of Earnings

U.S. Department of Labor

(Longshore and Harbor Workers' Compensation Act,
as Extended)

Employment Standards Administration
Office of Workers' Compensation Prgorams
www.dol.gov.esa/owcp/dlhwc/index.htm

Instructions to Employee: You are required to complete and sign this form and return it to the employer/insurance carrier/
special fund listed in item 4 within 30 days after receipt even if you have no earnings to report. (20 CFR 702.286) See page
2 for definition of "Earnings" and additional instructions. Loss of compensation benefits may result if this form is not
completed and filed in accordance with instructions.
1.

OMB No.: 1215-0160

2. OWCP No.
Name and Address of
Employee (Type or print)
3. Carrier's No.

4. Name of Employer/Insurance Carrier/ Special Fund

5. Address of Employer/ Insurance Carrier/ Special Fund

6. Period For Which Earnings From Employment or Self-Employment 7. Have You Had Any Earnings From Employment or Self-Employment During the
Must be Reported
Period Shown in item 6? (See page 2 for definition of "Earnings")
[ ] Yes
From

[ ] No

To

8. Complete the Following if You Had Earnings From Employment During the Period Shown in Item 6.
Periods of Employment

Name and Address of Employer

From

To

Amount Earned

9. Complete the Following If You Had Earnings From Self-Employment During The Period Shown in Item 6.
Type of Business or Service

Dates Performed
From

To

Gross Revenue
Received

Profits or Net Earnings
Received

10. I certify that the above information I have provided is true, complete and correct to the best of my knowledge and belief.

Signature and Print Name

Telephone No.

Date

IMPORTANT NOTICE
Section 31 (a)(1) of the Longshore Act, 33 U.S.C. 931 (a)(1), provides as follows: Any claimant or representative of a claimant who knowingly and willfully
makes a false statement or representation for the purpose of obtaining a benefit or payment under this Act shall be guilty of a felony, and conviction therof
shall be punished by a fine not to exceed $10.000, by imprisonment not to exceed five years, or both.
Form LS-200
Rev. April 2009

INSTRUCTIONS TO EMPLOYEE
You are required to report on this form all earnings from employment or self- employment earned during the period specified on page 1 of this form (20 CFR
702.286). An employee who fails to report his/her earnings when requested or knowingly and willfully omits or understates any part of such earnings may
forfeit his/her right to compensation with respect to any period during which this report is required. Compensation forfeited, if already paid, shall be deducted
from any future compensation which may be due in accordance with a schedule determined by the District Director of the Office of Workers' Compensation
Programs, Division of Longshore and Harbor Workers' Compensation, having jurisdiction in the case. (33 U.S.C. 908(j).

Earnings are defined as all monies received from any employment and includes but is not limited to wages, salaries, tips, sales commissions, fees for
services provided, piecework and all revenue received from self- employment even if the business or enterprise operated at a loss or if the profits were
reinvested.

An employer, insurance carrier, or the Director of the Office of Workers' Compensation Programs, Division of Longshore and Harbor Workers'
Compensation (for those cases being paid from the Special Fund) may require an employee to file this report semiannually. The information provided will be
used to determine entitlement to benefits.

FAILURE TO GIVE WRITTEN NOTICE MAY RESULT IN SOME LOSS OF BENEFITS.

PRIVACY ACT OF 1974 NOTICE
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a) you are hereby notified that (1) The Longshore and Harbor Workers'
Compensation Act, (LHWCA) as amended and extended (33 U.S.C. 901 et seq.) is administered by the Office of Workers' Compensation Programs of the
U.S. Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2) Information which the Office
has will be used to determine eligibility for and the amount of benefits payable under the LHWCA. (3) Information may be given to the employer which
employed the claimant at the time of injury, or to the insurance carrier or other entity which secured the employer's compensation liability. (4) Information
may be given to physicians and other medical service providers for use in providing treatment or medical/vocational rehabilitation, making evaluations and
for other purposes relating to the medical management of the claim. (5) Information may be given to the Department of Labor's Office of Administrative Law
Judges (OALJ), or other person, board or organization, which is authorized or required to render decisions with respect to the claim or other matter arising in c
connection with the claim. (6) Information may be given to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to
a decision under the LHWCA to determine whether benefits are being and have been paid properly, and where appropriate, to pursue salary/administrative
offset and debt collection actions required or permitted by law. (7) Failure to disclose all requested information may delay the processing of the claim, the
payment of benefits, or may result in an unfavorable decision or reduced level of benefits.

Public Burden Statement
The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995, as amended. The
authority for requesting the following information is 20 CFR 702.285. Use of this form is optional, however furnishing the information is required in order to
obtain and/or retain benefits. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor and a person is not required to
respond to, a collection of information unless is displays a valid OMB control number. The valid OMB control number for this information collection is 12150160. The time required to complete this informatin collection is estimated to average 10 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate or any aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of
Labor, Division of Longshore and Harbor Workers' Compensation, Room C-4315, 200 Constitution Avenue, N.W., Washington, D.C. 20210.

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.