Statement of Recovery Letter with Short Form

• Legal Form Number: CA-1122
• Issuer: Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation
• Section: U.S. Department of Labor

Date of judgment or release:

1. Gross Recovery (Entire amount of the award) $

2. Amount of Real or Personal Property Damage (Must be approved)

3. Subtotal A (Line 1 minus Line 2)

4. Amount for Loss of Consortium, if any

(Line 4 is % of Line 3)

5. Subtotal B (Line 3 minus Line 4)

6. Enter 20% of Line 5

7. Balance (Line 5 minus Line 6)

8. Enter Total Disbursements

9. Enter lower of Line 7 or Line 8

REFUND THIS AMOUNT TO OWCP

10. Surplus (Line 7 minus Line 8)

If Line 8 is greater than Line 7, enter "0".

CREDIT AGAINST FUTURE BENEFITS

CA-1122 (Rev. 04/24)

U.S. DEPARTMENT OF LABOR Office of Workers’ Compensation Programs

OMB No. 1240-0001

Expiration Date: 02/28/2025

SHORT FORM STATEMENT OF RECOVERY

(See following page for instructions)*

File Number:

Employee:

(Refundable Disbursements and Continuation of Pay (COP))

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