)) and the Energy Employees Occupational Illness Compensation Program Act of 2000, (42 USC 7384 and 20 CFR 30.701). While you are not required to respond, this information OMB No. 1240-0037 is required to obtain reimbursement for mileage. The method of collecting information complies with the Freedom of Information Act, the Expires: 11/30/2026 Privacy Act of 1974, and OMB Circ. 130. This form should be used for medically related travel covered by the Federal Employees' Compensation Act and the E.
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How to fill out the DOL OWCP-957 Part A online
Filling out the DOL OWCP-957 Part A form can be essential for obtaining reimbursement for medical travel mileage. This guide provides step-by-step instructions that are clear and concise to assist users in completing the form efficiently.
Follow the steps to fill out the form accurately
- Click ‘Get Form’ button to access the DOL OWCP-957 Part A form for completion.
- Enter the claimant's full name in the designated field, ensuring to include the last name, first name, and middle initial.
- Input the case or claim number associated with the individual seeking reimbursement.
- If the payee is not the claimant, provide their full name (last name, first name, middle initial) in the appropriate section.
- Enter the phone number for the claimant or payee, as this may be necessary for follow-up questions regarding the form.
- Fill in the complete address for the claimant or payee, including house number, street, city, state, and zip code. Ensure this is the home address and not a P.O. Box.
- Provide an email address for the claimant or payee for further communication related to the reimbursement.
- For every trip, fill out a separate block with the following details: date of travel, reason for travel, 'from' address (start location), 'to' address (destination), one-way or round trip selection, and the total number of miles traveled.
- Review the payee certification statement carefully, ensuring the information is accurate and true, before signing and dating the form.
- Once all fields are completed, you may save the changes, download a copy, print it, or share the form as necessary.
Take the next step and complete your DOL OWCP-957 Part A form online for a smoother reimbursement process.
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