Follow the steps to complete the form effectively

1. Click ‘Get Form’ button to obtain the form and open it in the editor. This will allow you to access all necessary fields required for completion.
2. Begin by entering the employer's name in the designated field. This information is crucial for identifying the organization associated with the claim. Ensure to include the full name without abbreviations.
3. Provide the employer's phone number. This should be a valid contact number for any inquiries related to the claim.
4. Fill in the employer's complete mailing address, including street address, city, state, and zip code. This ensures that all correspondence is directed to the right place.
5. Insert the employer's Tax Identification Number (TIN). This number is essential for processing the claim.
6. Input the employer's bill payment number if applicable. This might be relevant for any financial transactions during the claim process.
7. Enter the claimant’s name, including last name, first name, and middle initial. This information is needed to verify the identity of the person filing the claim.
8. Provide the OWCP file number associated with the claim. This helps in tracking and managing the claim effectively.
9. Note the date the employment began for the claimant. This information is necessary for determining eligibility.
10. Indicate the dates and hours worked, specifying both the starting and ending date, as well as the total hours worked during that timeframe.
11. Document the pay rate per hour. Accuracy is important here, as this will affect the reimbursement amount calculated.
12. Calculate and enter the total amount earned by the claimant during the specified period.
13. State the amount of reimbursement being claimed. This figure should reflect the expenses for which reimbursement is requested.
14. If the form is unsigned by the claimant, include a brief explanation in the comments section as required.
15. Sign and date the form to certify that all the information provided is correct. The supervisor also needs to add their signature if applicable.
16. Once all fields are completed, you may save changes, download, print, or share the form as necessary to submit it to the Division of Rehabilitation.

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