8. Enter payee's full name (if person other than the claimant is to be reimbursed): last name, first name, middle initial.
2. Claimant’s last name and OWCP Claim Number should be listed on submitted attachments. A payee other than the claimant must have special authorization. ���% �} �d; "Y#A$K%�� f{�ɕ`�8�&��� ��+;@l�t)xl�
1305 0 obj <>stream Instructions (Form OWCP-957) 1. ��O������,��HC�?�?� �jr I am aware that any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud, to obtain reimbursement as
1265 0 obj <> endobj ��h��CI�{�)�B�8:3��"�g�qEL�� �e�p%���]�Qw#��ܹ���B�wQ��$�eU�Fۭ�"��|�:���=�i Hyvc4%�����9� ab'�C}�O�A(c����!��NN�H㫄�g���I�����7E@P�EI[ %%EOF
µ¦X0ÉÑÄËé¨áééçP-Ğ€h"˪‡Á‰¼‚9. Enter payee's full name (if person other than the minor or claimant is to be reimbursed): last name, first name, middle initial. Enter claimant's full name: last name, first name, middle initial. Caution, you must submit your request for travel pay on form OWCP Form 957 – Medical Travel Refund Request within one year of the travel. �\S|;}\ڬ��˕�]�ؓW5*H�e\0���_�9�j� �v�V��ZHO~�H��5�^������C.�i��s�x��������h˹Q/?���;E��x�p�j��έ����E ��=S�C=d�4�ϻW���/3��$H���GB�c���
%PDF-1.6 %���� 3. %PDF-1.7 %���� Black Lung Claimants: • Travel expenses for the miner are reimbursable
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OWCP-957 Medical Travel Refund Request OWCP-957 Medical Travel Refund Request (This form is available at http://www.dol.gov/esa/owcp/dfec/regs/compliance/OWCP-957.pdf.)
860 0 obj <> endobj 1256 0 obj <>stream Requirements for Reimbursement of the OWCP 957 Form Original receipts are required for lodging, airfare, rental car, and any other expense that exceeds $75. 2. Enter claimant's Social Security Number. â„m€ ì.PàAPG—ƒ÷ò^ŞËQX¿^ì.9⻽;ñø?/Rì\í¶ıßÉpÇÍïI,l ³Ó™3ÁÏK³Åğ]šæ5àyu6z*Ò’”‚¾3ø”܃H�‚j‡ø:¸3xX» 1287 0 obj <>/Encrypt 1266 0 R/Filter/FlateDecode/ID[<58234E040D34224D8A18C99994683983>]/Index[1265 41]/Info 1264 0 R/Length 110/Prev 820355/Root 1267 0 R/Size 1306/Type/XRef/W[1 3 1]>>stream
1056 0 obj <>/Encrypt 861 0 R/Filter/FlateDecode/ID[<1ED6AA8FD0AF6543A27056A41BA128EC>]/Index[860 397]/Info 859 0 R/Length 232/Prev 669482/Root 862 0 R/Size 1257/Type/XRef/W[1 3 1]>>stream ���>�� ":R�8�}�ֻLk�:�,�Q /! Enter claimant's full name: last name, first name, middle initial.
%%EOF Keep a copy for your records. OWCP pays the claimant for travel to and from the medical provider, to and from any therapy treatments, and to and from the pharmacy for medicine used for the injuries. �@Fg�-T��(Xz A��B,����o`k�"� �7x ��a� ��������BX����%���!���\ ���#�rA��0�F������b�0%My��`�c�uLm,QC:�˹���� ? Payee's Certification: I certify that the information provided is true and accurate to the best of my knowledge and belief.
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Instructions (Form OWCP-957) 1. Form OWCP-957 Revised February 2017.
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