Overpayment Recovery 

Questionnaire

U.S. Department of Labor 

Office of Workers’ Compensation Programs 

Overpaid Person - Last Name Claim No.

EVERYONE MUST COMPLETE PART I, PART II, AND PART V, 

COMPLETE THE FOLLOWING PARTS ONLY IF MARKED:

PART III PART IV

OMB No.: 1240-0051 

Expires: 09/30/2025

Part I - Possession of Overpayment (to be completed by all applicants for waiver)

1. Do you have any of the incorrectly paid checks or payments in your possession?

Yes No

If “Yes”, show the total amount: $_____________________. (These funds should be returned to the U.S. Department of Labor immediately).

2. Since you were notified of the overpayment, have you transferred by loan, gift, sale, etc. any property or cash? 

If "Yes", explain:

Yes No

First Name MI

Claimant - Last Name First Name MI

Revised 07-22 

Previous editions unusable OWCP-20 (Rev. 07-22) 
Part II - REFUND QUESTIONNAIRE 

(To be completed by the person for whom repayment of the overpayment would cause undue hardship)

3. List your monthly income (Including any income of your spouse or any dependent 

relative living in the household with you) from:

Monthly Income

Social Security Benefits

Supplemental Security Income Payment

State or Local Welfare Payment. Specify:

Other benefits, such as Veterans Administration, Civil Service, Unemployment, Black Lung, FECA, 

Railroad, Private Pension, etc. Specify: 

Earnings (take-home wages and average net earnings from self-employment). Specify:

Other income, such as dividends, interest, rentals, roomers or boarders, etc. Specify:

Total Monthly income

4. Do you support, either fully or in part, anyone other than yourself? 

 If "Yes", give the following information about each person you support: Yes No

Name Address Age Relationship To You 

(If None, Enter "None")

OWCP-20 Page 2 (Rev. 07-22) 

Revised 07-22 

Previous editions unusable 

5. List the usual expenses of your household on a monthly basis Monthly Payment

Rent or Mortgage, including Property Tax

Food

Clothing

Utilities (electricity, gas, fuel, telephone, water)

Other Debts Being Paid By Monthly Installments

Creditor Amount Owed Monthly Payment

$

$

Other expenses (Such as: Miscellaneous household expenses, medical and dental care (not 

covered by insurance), automobile expenses or other transportation costs, personal necessities.)

Total Monthly Expenses

$

$

$

$

$

$

$

$

$

$

$

$

$
6. Not counting your home, family automobile, or household furnishings, 

do you or your spouse own any valuable property or real estate?

OWCP-20 Page 3 (Rev. 07-22) 

Revised 07-22 

Previous editions unusable 

Yes No

If "Yes", specify and give current market value. If mortgage, show amount of mortgage.

7. List below any funds you have (including those of your spouse, if you live with your spouse):

a. Cash on hand

b. Checking account balance

c. Savings account balance

d. Current value of any stocks and bonds

e. Value of other personal property and other funds

TOTAL

f. Name of stocks and bonds you have (use separate sheet if 

space is insufficient).

g. Name and address of financial institutions(s)

PART III - WITHOUT FAULT STATEMENT

8. Explain fully why you thought the incorrect payment was due to you and why the overpayment was not your fault:

9. Did you report the change in circumstances which affected your monthly payment? 

If "Yes", when did you report? (Give date):

Yes No There was no change

If "No", why didn't you report?

$

$

$

$

$
OWCP-20 Page 4 (Rev. 07-22) 

Revised 07-22 

Previous editions unusable 

10. When were the conditions under which you could receive payments first explained to you?

11. Do you NOW fully understand reporting responsibilities? Yes No If "No", explain:

PART IV - REPRESENTATIVE PAYMENT MADE 

(to be completed ONLY by a representative payee)

12. Give the name and present address of the person for whom you received payment:

13. Were the incorrect payments used for this person? Yes No

Explain:

PART V

14. Remarks (optional):

I know that anyone who makes or causes to be made a false statement or representation of material fact in an application or for use in 

determining a right to payment under the BLBA, EEOICPA and FECA commits a crime punishable under Federal and/or State law. I affirm 

that all information I have given in this document is true.

(Signature of Overpaid Person or Representative Payee) (Date - Month, day, year)

(Telephone Number)

Mailing Address (Number and Street, Apt. No., P.O. Box, Rural Route)

City State Zip County (if any) in which you now live:
OWCP-20 Page 5 (Rev. 07-22) 

Revised 07-22 

Previous editions unusable 

Privacy Act Statement 

Collection of this information by OWCP is authorized by section 8129(b) of the Federal Employees' 

Compensation Act (5 USC 8129(b)), section 413(b) of the Black Lung Benefits Act (30 USC 923(b)) and 

section 7385j-2 of the Energy Employees Occupational Illness Compensation Program Act (42 USC 

7385j-2). The information provided will be used to determine the extent to which overpayments of 

benefits will be recovered and is fully protected by the Privacy Act of 1974, as amended (5 USC 552a) 

under the following systems of records: DOL/GOVT-1, published in the Federal Register, Vol. 81, page 

47418, July 21, 2016, DOL/OWCP-2, DOL/OWCP-9, and DOL/OWCP-11, published in the Federal 

Register, Vol. 81, page 25766, April 29, 2016, or as updated and republished. This information may be 

disclosed to private collection agencies under contract with the Departments of Labor, Justice or 

Treasury, or to the Department of Justice for litigation purposes. Additional disclosures may be made 

through the routine uses for information contained in the referenced systems of records.

Public Burden Statement 

Under the Paperwork Reduction Act, persons are not required to respond to a collection of information 

unless such collection displays a valid OMB control number. Completion and submission of this form is 

voluntary; however, failure to provide the information may result in the denial of a request to waive 

recovery of the overpayment. We estimate that it will take an average of 60 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 this estimate or any other aspect of this collection of information, 

including suggestions for reducing this burden, send them to the Direct or , U.S. Department of Labor, 

Office of Workers’ Compensation Programs, Room S- 3524, 200 Constitution Avenue NW, Washington, 

DC 20210. DO NOT SEND THE COMPLETED FORM TO THIS ADDRESS.

Accommodation Statement 

If you have a disability and are in need of communication assistance (such as alternate formats or sign 

language interpretation), accommodations and/or modifications, please contact OWCP.