Form OWCP-17 Rehabilitation Maintenance Certificate

U.S. Department of Labor

Rehabilitation Maintenance Certificate
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Office of Workers' Compensation Programs

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No monies or benefits can be paid under this program unless this report is completed and filed as requested by law (5 U.S.C.
8111;33 U.S.C. 901 as extended and amended). The information collected will be handled and stored in compliance with the
Freedom of Information Act, Privacy Act of 1974 and OMB Cir. No. 180.
1. Name of Injured Worker (First, Middle Initial, Last)

3. Maintenance Payment Per Week.

2. OWCP No.

5. Appropriate Act (Mark X)

4. Maintenance Pay Period (Month, Day, Year)
From

$

OMB No.1240-0012
Expires: XX-XX-XXXX

Federal Employees' Compensation Act

Thru

Longshore and Harbor Workers' Compensation Act
District of Columbia Compensation Act
PLEASE READ CAREFULLY - Submit both copies of this two part form to the Rehabilitation Specialist in the District Office.
Complete items 6 thru 8, typing, or printing clearly with a ball point pen; then sign your name legibly in item 9. Next have an official at
your facility certify your statement by completing items 10 thru 12.
INJURED WORKER

6. Days Absent From Program (Month, Day, Year)

7. Reason For Absence(s)

8. Complete Mailing Address (No., Street, City, State, ZIP Code)
Address Line 1
Address Line 2
City

State

ZIP

9. INJURED WORKER: I certify that I participated in my rehabilitation program, as prescribed by the Office of Workers' Compensation
Programs, and hereby request a maintenance payment for the above period.
Signature

Date Signed

OWCP REHABILITATION SPECIALIST
OR REHABILITATION COUNSELOR

FACILITY
OFFICIAL

10. Name

11. Title

12. FACILITY OFFICIAL: I certify that the above statement in item 6 is true.
Signature

Date Signed

13. REMARKS:

14. Amount Approved

15. District Office No.

16. OWCP REHABILITATION SPECIALIST or REHABILITATION COUNSELOR:
I recommend the amount approved be paid to the injured worker.
Signature

Date Signed

FOR OWCP USE ONLY
Public Burden Statement
We estimate that it will take an average of 10 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 these estimates or any other aspect of this information, including suggestions for reducing this burden, send them to the U.S.
Department of Labor, OWCP, Room S-3524, 200 Constitution Avenue, N.W., Washington, D.C. 20210. Note: Persons are not required to respond
to this collection of information unless it displays a currently valid OMB control number.
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.
Notice
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.
Previous editions usable

OWCP-17 (Rev. 04-12)