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 Refundable 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. 02/22)

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:
CERTIFICATION 

 

I understand that anyone who fraudulently conceals or fails to report information that would 

have an effect on any benefits, or who makes a false statement or misrepresentation of a 

material fact in claiming a payment or benefit under the Federal Employees’ Compensation Act 

may be subject to criminal prosecution, from which a fine and/or imprisonment may result.

 

I certify that the above statements made on this Form CA -1122 are true, complete and correct 

to the best of my knowledge and belief. I also certify that the information on this form does/does 

not (circle one) represent my settlement with all defendants in the case, and that I have/do not 

have (circle one) other cases or claims pending or unresolved against any other third parties 

liable for the same injuries for which FECA benefits have been paid or are payable.

Signature Date

(For use by U.S. Department of Labor only) 

*Attorneys must use the Form CA-1108, Long Form Statement of Recovery.

Approved: Date: 

WARNING 

 

A FALSE OR EVASIVE ENTRY ON FORM CA-1122, OR THE OMISSION OF AN ENTRY ON THE 

FORM, MAY SUBJECT YOU TO CIVIL LIABILITY. A FRAUDULENT ENTRY MAY RESULT IN 

CRIMINAL PROSECUTION. ALL ENTRIES ON FORM CA-1122 ARE SUBJECT TO INVESTIGATION 

FOR VERIFICATION. 

 

Following your submission of the CA-1122, you will be advised further of your compensation status. 

 

If you should retain the services of an attorney to assist you in your third-party claim, please advise this 

office immediately and provide the attorney’s name and complete address.

CA-1122 PAGE 2 (Rev. 02/22) 
PRIVACY ACT STATEMENT

The following statement is made in accordance with the Privacy Act of 1974 (5. U. S. C. 552a). The 

authority for requesting the information is the Federal Employees’ Compensation Act (5 U. S. C. 8101 et 

seq). Information collected will be handled and stored in compliance with the Freedom of Information Act 

and the Privacy Act of 1974, as amended (5 U.S.C. 552a). The information will be used to determine 

the amount of refund due to the United States out of the proceeds of a third party action. Failure to 

furnish the requested information will result in a delay in processing the third party recovery. In addition 

to those Department-wide routine uses set forth above in the General Prefatory Statement to this 

document, disclosure of information from this system of records may be made to the following 

individuals and entities for the purposes noted when the purpose of the disclosure is both relevant and 

necessary and is compatible with the purpose for which the information was collected: to any attorney or 

other representative of a FECA beneficiary for the purpose of assisting in a claim or litigation against a 

third party or parties potentially liable to pay damages as a result of the FECA beneficiary's FECAcovered injury and for the purpose of administering the provisions of sections 8131-8132 of the FECA. 

Any such third party, or a representative acting on that third party's behalf, may be provided information 

or documents concerning the existence of a record and the amount and nature of compensation paid to 

or on behalf of the FECA beneficiary for the purpose of assisting in the resolution of the claim or litigation 

against that party or administering the provisions of sections 8131-8132 of the FECA. DOL/GOVT-1 

(Office of Workers' Compensation Programs, Federal Employees' Compensation Act File) 81 FR 47418, 

July 21, 2016.

PUBLIC BURDEN STATEMENT

We estimate that it will take an average of 15 minutes to respond to this collection of information, which 

includes time for reviewing instructions, searching existing data sources, gathering and maintaining the 

data needed, and completing and reviewing the collection of information. A respondent’s obligation to 

respond is required in accordance with 5 U.S.C. 8131-8132 of the FECA to obtain or retain benefits. 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 U.S. Department of Labor, OWCP, 

Room S-S3229, 200 Constitution Avenue, NW, Washington, DC 20210 and reference the OMB control 

number. DO NOT SEND THE COMPLETED FORM TO THIS ADDRESS. According to the Paperwork 

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

collection displays a valid OMB control number.

CA-1122 PAGE 3 (Rev. 02/22)

NOTICE

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.
INSTRUCTIONS FOR FORM CA-1122

*Distribution of the proceeds from the third-party recovery must be made in accordance with 5 U.S.C. 8132.*

Line 1 - GROSS RECOVERY - The entire amount of any award received as a result of a judgment entered in a 

lawsuit, settlement of a lawsuit, or any other settlement or recovery from a responsible third party, must be 

entered on Line 1 as the gross recovery.

Line 2 - PROPERTY DAMAGE - A reasonable amount for clothing or other personal belongings that are damaged 

or destroyed in an accident may be deducted. These amounts must be itemized. If an automobile or other vehicle 

is damaged or destroyed, furnish the year, make and model, and the Blue Book value of the vehicle, along with an 

estimate of the damage declaring the vehicle to be a total loss. A copy of the repair bill will suffice if the vehicle 

was not totally destroyed.

Line 4 - LOSS OF CONSORTIUM - OWCP or SOL (or whoever else has been delegated the authority) will 

determine a reasonable allocation of the judgment or settlement for loss of consortium, unless the judgment is 

from a contested verdict, then those allocations will be used. The amount allocated for loss of consortium must be 

a percentage of the amount on Line 3, and must be approved by OWCP or SOL (or other delegated authority). A 

reasonable allocation for a spouse's loss of consortium will be up to 25% of Line 3 and for a child or children's loss 

of consortium up to 5% per child, to a maximum of 15% for all children of Line 3 (total combined 40%). The 

approved allocation must be expressed as a percentage of the amount on Line 3 in the space provided. The 

beneficiary must establish that loss of consortium was asserted in the suit or claim, and that loss of consortium 

claims are permitted under the state law where the action was brought. FECA beneficiaries may accept the 

determination of the percentage allocated or demonstrate good cause in writing for a different percentage to be 

allocated for loss of consortium

Line 6 - 20% GUARANTEE - Multiply Line 5 by 20% and enter the result on Line 6. This amount is retained by 

you and is not subject to any deductions.

Line 8 - OWCP DISBURSEMENTS - All amounts paid by OWCP (compensation and medical benefits, but not 

continuation of pay (COP)) less the gross amount of any prior refunds made (from Line 7 on any earlier EN-1122 

or CA-1122) are to be entered in the space provided. 

Line 9 - REFUND TO OWCP - Compare Line 7 with Line 8 (refundable disbursements), and enter the lower of 

the two on Line 9. This is the amount to be refunded to OWCP. NOTE: You must contact OWCP to obtain a 

current history of the disbursements made to you and your medical providers for compensation and medical 

benefits.

Line 10 - CREDIT AGAINST FUTURE BENEFITS (SURPLUS) - If Line 7 is less than Line 8 (Refundable 

Disbursements), there is no credit to be applied against future benefits. If Line 7 is greater than Line 8, a credit 

against future benefits must be applied and is determined by subtracting Line 8 from Line 7. The surplus is 

retained by you and is the amount against which OWCP will credit future compensation payable on account of the 

same injury. Because you will not be entitled to any further payments from OWCP until you are eligible for 

additional compensation in an amount greater than the surplus, you should submit all medical bills you have paid 

for the injury to OWCP, regardless of when you paid them. You will not be reimbursed for these payments, but the 

amount you paid will be used to reduce the amount of the surplus.

The refund check for the amount shown in Line 9 should be made payable to the "U.S. Department of Labor, 

OWCP”. PLEASE INCLUDE THE OWCP FILE NUMBER ON THE CHECK.

Unless directed otherwise, send refund check to: 

U.S. Department of Labor 

Office of the Solicitor 

200 Constitution Avenue NW 

Room S4325 

Washington, DC 20210.

CA-1122 PAGE 4 (Rev. 02/22)