Official Federal Forms > US Dept Of Labor

Medical Travel Refund Request OWCP-957 - Official Federal Forms

Medical Travel Refund Request Form. This is a national form and can be used in US Dept Of Labor .
 Fillable pdf Last Modified 11/22/2010
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The claimant's full name and Social Security Number should appear on each receipt. FOR BLACK LUNG USE ONLY Note: 2QO\ WUDYHO H[SHQVHV IRU WKH PLQHU DUH UHLPEXUVDEOH 6SHFLDO DSSURYDO IURP WKH GLVWULFW RIILFH LV QHHGHG IRU ORGJLQJ RU IRU WUDYHO H[FHHGLQJ PLOHV RQH ZD\ RU PLOHV URXQGWULS 7R REWDLQ \RXU GLVWULFW RIILFH WHOHSKRQH QXPEHU FDOO WROO IUHH 5HLPEXUVHPHQW IRU PHDOV ZLOO EH PDGH RQO\ ZKHQ DXWKRUL]HG WUDYHO H[FHHGV KRXUV RU XQGHU VSHFLDO FLUFXPVWDQFHV 7UDYHO WR SLFN XS PHGLFLQH HTXLSPHQW RU VXSSOLHV LQ QRW UHLPEXUVDEOH FOR ENERGY EMPLOYEES ONLY Note: 6SHFLDO DSSURYDO IURP WKH GLVWULFW RIILFH LV QHHGHG IRU RYHUQLJKW RU DLU WUDYHO RU IRU WUDYHO H[FHHGLQJ PLOHV RQH ZD\ RU PLOHV URXQGWULS 7R REWDLQ \RXU GLVWULFW RIILFH WHOHSKRQH QXPEHU FDOO WROO IUHH Public Burden Statement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ersons are not required to respond to this collection of Information unless it displays a currently valid OMB control number. American LegalNet, Inc. www.FormsWorkFlow.com
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