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Federal forms, ICRs, and supporting documents

Information Collection

Uniform Billing Form (OWCP-04)

IC 38466 under ICR 202501-1240-003 · OMB 1240-0019.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

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Uniform Billing Form (OWCP-04)
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 725.704 20 CFR 30.701 20 CFR 725.405 20 CFR 10.801 20 CFR 725.406 20 CFR 725.701

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction OWCP-04 Uniform Billing Form 1240-0019 OWCP-04-updated 2025.pdf http://www.dol.gov/owcp/dfec/regs/compliance/OWCP-04.pdf Yes Yes Fillable Printable

Health Health Care Services

DOL/GOVT-1(for FECA); DOL/OWCP-2(for BLBA); DOL/OWCP-11 (for EEOICPA)  81 FR 64529

7,549 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   97 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 198,830 0 -47,475 0 0 246,305
Annual IC Time Burden (Hours) 16,420 0 -8,264 0 0 24,684
Annual IC Cost Burden (Dollars) 1,359,162 0 1,359,162 0 0 0

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.