Rehabilitation Maintenance Certificate U.S. Department of Labor 

Office of Workers' Compensation Programs

IMPORTANT: No monies or benefits can be paid under this program unless this report is completed and filed as requested by 

law (5 U.S.C. 8111;33 U.S.C. 901 as extended and amended). The information collected will be handled and stored in 

compliance with the Freedom of Information Act, Privacy Act of 1974 and OMB Cir. No. 130. 

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. See additional guidance below for REQUESTS FOR 

ACCOMMODATIONS OR AUXILIARY AIDS AND SERVICES. 

OMB No.1240-0012 

Expires: 04/30/2025

1. Name of Injured Worker (First, Middle Initial, Last) 2. OWCP No.

3. Complete Mailing Address (No., Street, City, State, ZIP Code)

Address Line 1

Address Line 2

City State ZIP

4. Maintenance Payment Per Week

$

5. Maintenance Pay Period (Month, Day, Year)

From Thru Federal Employees' Compensation Act

Longshore and Harbor Workers' Compensation Act

6. Appropriate Act (Mark X)

INJURED WORKER

PLEASE READ CAREFULLY - Submit this form to the Rehabilitation Counselor assigned to your case by OWCP. Complete items 7 

thru 9, typing, or printing clearly with a ball point pen; then sign your name legibly in item 10. Next have an official at your facility certify 

your statement by completing items 11 thru 13.

7. Weekly Training Schedule Monday Tuesday Wednesday Thursday Friday Saturday Sunday Other

8. Days Absent From Program (Month, Day, Year) 9. Reason For Absence(s)

10. INJURED WORKER: I certify that I participated in my rehabilitation program, as prescribed by the Office of Workers' 

Compensation Programs, and hereby request a maintenance payment for the above period.

Signature Date Signed

11. Name 12. Title

13. FACILITY OFFICIAL: I certify that the above statement in item 8 is true.

Signature Date Signed

14. REMARKS:

15. Amount Approved 16. District Office No.

FACILITY 

OFFICIAL

OWCP REHABILITATION SPECIALIST 

OR REHABILITATION COUNSELOR

17. OWCP REHABILITATION SPECIALIST or REHABILITATION COUNSELOR:

I recommend the amount approved be paid to the injured worker.

Signature Date Signed

Print Name

REQUESTS FOR ACCOMMODATIONS OR AUXILIARY AIDS AND SERVICES 

IF YOU HAVE A DISABILITY, FEDERAL LAW GIVES YOU THE RIGHT TO RECEIVE HELP FROM THE OWCP IN THE FORM OF 

COMMUNICATION ASSISTANCE, ACCOMMODATION(S) AND/OR MODIFICATION(S) TO AID YOU IN THE OWCP CLAIMS PROCESS. FOR 

EXAMPLE, WE WILL PROVIDE YOU WITH COPIES OF DOCUMENTS IN ALTERNATE FORMATS, COMMUNICATION SERVICES SUCH AS 

SIGN LANGUAGE INTERPRETATION, OR OTHER KINDS OF ADJUSTMENTS OR CHANGES TO ACCOMMODATE YOUR DISABILITY. 

PLEASE CONTACT OUR OFFICE OR YOUR OWCP CLAIMS EXAMINER TO ASK ABOUT THIS ASSISTANCE.

OWCP-17 (Rev. 02-19)

FOR OWCP USE ONLY

Previous editions usable 
Privacy Act Statement 

In accordance with the Privacy Act of 1974, as amended (5. U.S.C. 552a), you are hereby notified that (1) the Federal Employees Compensation 

Act (FECA) as amended and extended (5 U.S.C. 8101, et seq.) and the Longshore and Harbor Workers' Compensation Act (LHWCA), as amended 

and extended (33 USC 901 et seq.) are administered by the Office of Workers' Compensation Programs of the U.S. Department of Labor, which 

receives and maintains personal information on claimants and their immediate families. (2) Information which the Office has will be used to 

determine eligibility for and the amount of benefits payable under the FECA and LHWCA and may be verified through computer matches or other 

appropriate means. (3) Information may be given to the Federal agency which employed the claimant at the time of injury in order to verify 

statements made, answer questions concerning the status of the claim, verify billing, and to consider issues relating to entitlement to benefits or 

other relevant matters. (4) Information may be given to Federal, state, and local agencies for law enforcement purposes, to obtain information 

relevant to a decision under the FECA and LHWCA to determine whether benefits are being paid properly, including whether prohibited dual 

payments are being made, and, where appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by the 

FECA and LHWCA and/or the Debt Collection Act. (5) Failure to disclose all requested information may delay the processing of the claim or the 

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

Public Burden Statement 

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 estimated to be 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. The obligation to respond to this collection is required to obtain a benefit (5 U.S.C. 8101 and 33 U.S.C. 901). Send comments regarding 

the burden estimate or any aspect of this collection of information, including suggestions for reducing this burden, to the Office of Workers' 

Compensation Programs, Department of Labor, Room S-3229, 200 Constitution Avenue, NW, Washington, DC 20210, and reference the OMB 

Control Number 1240-0012. Note: please do not send the completed form to this office.

Previous editions usable OWCP-17 Page 2 (Rev. 02-19)