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Get DoL OWCP-957 2003

Ation: I hereby certify that the information given by me on and in connection with this form is true and correct to the best of my knowledge and belief. I am aware that any person who knowingly makes any false statement or misrepresentation to obtain reimbursement from OWCP is subject to civil penalties and/or criminal prosecution. Claimant's/Payee's Signature: Date: Form OWCP-957 Rev. Aug 2003 Instructions (Form OWCP-957) 1. Enter claimant's full name: last name, first name, middle initial. .

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