OMB control number

Rehabilitation Maintenance Certificate

OMB 1240-0012 · DOL/OWCP.

OMB 1240-0012

Form OWCP-17 serves as a bill submitted by the program participant or OWCP, requesting reimbursement of expenses incurred due to participation in an approved rehabilitation effort for the preceding four-week period or fraction thereof.

The latest form for Rehabilitation Maintenance Certificate expires 2028-04-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form OWCP-17 Rehabilitation Maintenance Certificate Form
1240-0012 Supporting Statement 2025.docx Supporting Statement A
Rehabilitation Counselors Wages.pdf Supplementary Document
Office of Workers' Compensation Programs Longshore and Harbor Workers' Compensation Act Case Files.docx Supplementary Document
Privacy Act Systems-FECA.docx Supplementary Document
Office of Workers' Compensation Programs, Longshore and Harbor Worker's Compensation Act Special Fund System.docx Supplementary Document
Rehabilitation Maintenance Certificate Form

All Historical Document Collections

202502-1240-004	Revision of a currently approved collection	2025-03-21
202110-1240-001 Approved with change	Extension without change of a currently approved collection	2022-01-14
202008-1240-063	No material or nonsubstantive change to a currently approved collection	2020-12-15
201805-1240-007 Approved without change	Revision of a currently approved collection	2018-11-30
201503-1240-001 Approved with change	Revision of a currently approved collection	2015-07-23
201112-1240-001 Approved without change	Revision of a currently approved collection	2012-06-28
201003-1240-012 Approved without change	Extension without change of a currently approved collection	2010-03-12