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Claim For Reimbursement Assisted Reemployment CA-2231 - Official Federal Forms
| Claim For Reimbursement Assisted Reemployment Form. This is a national form and can be used in US Dept Of Labor . |
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Claim For Reimbursement U.S. Department of Labor Employment Standards Administration Assisted Reemployment Office of Workers Compensation Programs Instructions: Complete items 1 through 16 and send to the Division of Re habilitation. If item 5 does not apply to you leave it blank.OMB No. 1215-0178No further monies may be paid out under this program unless this report is completed and filed, as required by terms of theExpires: 06-30-2007Cooperative Agreement entered into by you and OWCP. (P.L. 106.554) 1. Employers Name 2. Phone Number 3. Employers Complete Mailing Address: 4. Employers Tax I.D. No. Street or Post Office Box Number 5. Employer (Federal) Appropriations Code City State ZIP Code 7. OWCP File Number 6. Claimants Name Last First M.I 8. Social Security Number 10. Reporting Quarter 9. Date Employment Began Month Day Year 11. Dates and Hours Worked 12. Pay Rate Per Hour 13. Total Amount Earned 14. Amount of Reimbursement Claimed I certify that the information provided on this form is true and correct to the best of my knowledge. 15. Supervisors Signature 16. Date For OWCP Use Only Below This Space: Percentage Allowed: % Total Amount This Payment $ Authorized by: Date: Public Burden Statement We estimate that it will take an average of 30 minutes per response to c omplete this information collection, including the time forreviewing instructions, searching existing data sources, gathering and m aintaining the data needed, and completing and reviewing thecollection of information. If you have any comments regarding this burde n estimate or any other aspect of the survey, includingsuggestions for reducing this burden, send them to the U.S. Department o f Labor, Office of Workers Compensation Programs, RoomS3229, 200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED SURVEY TO THE ABOVE OFFICE Persons are not required to respond to this collection of information un less it displays a currently valid OMB control number. Form CA-2231 June 2004
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