9. Complete the following if you had earnings from self-employment during the period shown in item 6.

Type of Business or Service

Dates Performed Gross Revenue 

Received

Profits or Net Earnings 

From To Received

10. I certify that the above information I have provided is true, complete and correct to the best of my knowledge and belief.

Signature Telephone No. Date

IMPORTANT NOTICE

Section 31 (a)(1) of the Longshore Act, 33 U.S.C. 931 (a)(1), provides as follows: Any claimant or representative of a claimant who knowingly 

and willfully makes a false statement or representation for the purpose of obtaining a benefit or payment under this Act shall be guilty of a 

felony, and conviction thereof shall be punished by a fine not to exceed $10.000, by imprisonment not to exceed five years, or both.

OMB No.: 1240-0014

4. Name of Employer/Insurance Carrier/ Special Fund 5. Address of Employer/ Insurance Carrier/ Special Fund

Form LS-200 

Rev. Nov 2023

2. OWCP No.

Instructions to Employee: You are required to complete and sign this form and return it to the employer/

insurance carrier/ special fund listed in item 4 within 30 days after receipt even if you have no earnings to report. 

(20 CFR 702.286) See page 2 for definition of "Earnings" and additional instructions. Loss of compensation 

benefits may result if this form is not completed and filed in accordance with instructions.

as Extended)

(Longshore and Harbor Workers' Compensation Act,

Report of Earnings U.S. Department of Labor

Office of Workers' Compensation Programs

https://www.dol.gov/agencies/owcp/dlhwc

Name and Address of

Employee (Type or print) 

1.

3. Carrier's No.

name

 line1

 line2

city

st zip

country

last first mi.

 line1

 line2

city

st zip

6. Period for which earnings from employment or selfemployment must be reported

8. Complete the following if you had earnings from employment during the period shown in item 6.

7. Have you had any earnings from employment or self-employment during the 

period shown in item 6? (See page 2 for definition of "earnings")

From To Yes No

Name and Address of Employer Amount Earned From To

Periods of Employment

name city

st zip

city

st zip

name

name city

st zip

Print Name

Expires: 11/30/2026
You are required to report on this form all earnings from employment or self- employment earned during the period specified on page 1 of this 

form (20 CFR 702.286). An employee who fails to report his/her earnings when requested or knowingly and willfully omits or understates any 

part of such earnings may forfeit his/her right to compensation with respect to any period during which this report is required. Compensation 

forfeited, if already paid, shall be deducted from any future compensation which may be due in accordance with a schedule determined by the 

District Director of the Office of Workers' Compensation Programs, Division of Federal Employees', Longshore and Harbor Workers' 

Compensation, having jurisdiction in the case. (33 U.S.C. 908(j).

INSTRUCTIONS TO EMPLOYEE

Public Burden Statement

PRIVACY ACT STATEMENT

FAILURE TO GIVE WRITTEN NOTICE MAY RESULT IN SOME LOSS OF BENEFITS.

Privacy Act of 1974 as amended (5 U.S.C. 552a), section 901 of Title 33 to the US Code and 20 CFR 702.285 authorizes collection of this 

information. The purpose of this information is to determine eligibility for the amount of benefits payable under the Longshore and Harbor 

Workers' Compensation Act (LHWCA). Completion of this form is not mandatory; however, failure to provide the information may result in the 

loss of compensation benefits. Additional disclosures of this information may be to: (1) the employer which employed the claimant at the time 

of injury, or to the insurance carrier or other entity which secured the employer's compensation liability. (2) Physicians and other medical 

service providers for use in providing treatment or medical/vocational rehabilitation, making evaluations and for other purposes relating to the 

medical management of the claim. (3) the Department of Labor's Office of Administrative Law Judges (OALJ), or other person, board or 

organization, which is authorized or required to render decisions with respect to the claim or other matter arising in connection with the claim. 

(4) Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the LHWCA to 

determine whether benefits are being and have been paid properly, and where appropriate, to pursue salary/administrative offset and debt 

collection actions required or permitted by law. (5) Failure to disclose all requested information may delay the processing of the claim, the 

payment of benefits, or may result in an unfavorable decision or reduced level of benefits.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection 

displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 10 minutes per 

response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and 

completing and reviewing the collection of information. Use of this form is optional, however furnishing the information is required in order to 

obtain and/ or retain benefits. (20 CFR 702.285). Send comments regarding the burden estimated or any other aspect of this collection of 

information, including suggestions for reducing this burden, to the U.S. Department of Labor, 200 Constitution Avenue, NW, Room S-3229, 

Washington, D.C. 20210 and reference the OMB Control number.

An employer, insurance carrier, or the Director of the Office of Workers' Compensation Programs, Division of Federal Employees', 

Longshore and Harbor Workers' Compensation (for those cases being paid from the Special Fund) may require an employee to file this 

report semiannually. The information provided will be used to determine entitlement to benefits. Persons are not required to respond to 

the collection of information unless it displays a currently valid OMB control number. 

Earnings are defined as all monies received from any employment and includes but is not limited to wages, salaries, tips, sales commissions, 

fees for services provided, piecework and all revenue received from self- employment even if the business or enterprise operated at a loss or 

if the profits were reinvested.

Form LS-200 

Rev. Nov 2023 

Page 2