How to Fill Out DOL Form CA-1122 (w/Examples) + FAQs

Yes, you can complete DOL Form CA-1122 correctly by reading every line carefully, gathering your medical and employment records before you start, and signing only after you confirm every fact is true. The form is a sworn statement that the U.S. Department of Labor’s Office of Workers’ Compensation Programs uses to verify your continued eligibility for federal injury benefits under the Federal Employees’ Compensation Act (FECA). A wrong checkbox, a missed signature, or a forgotten side job can cost you your benefits.

The trouble starts the moment you guess. OWCP treats CA-1122 as a federal affidavit, which means false answers can trigger criminal charges under 18 U.S.C. § 1920 and 18 U.S.C. § 1001, plus full forfeiture of your compensation. The rules sit inside 20 CFR Part 10, the binding regulation that controls every FECA claim. One missed deadline under that rule can shut your file before a claims examiner ever reads your medical proof.

According to the DOL Office of Inspector General, federal workers’ compensation fraud investigations recovered more than $77 million in a recent reporting year, and most cases began with a false or incomplete affidavit. That single number shows why this form matters far more than its size suggests.

Here is what you will learn in this guide:

• 📝 How to fill out every line of CA-1122 without triggering a denial
• ⚖️ Which federal statutes and OWCP rules control your answers
• 💼 How outside earnings, self-employment, and volunteer work must be reported
• 🚫 The seven most common mistakes that cause claim suspension
• 🧾 Real examples, FAQs, and a do/don’t checklist you can use today

What Is DOL Form CA-1122?

DOL Form CA-1122 is a sworn affidavit used by the Division of Federal Employees’, Longshore and Harbor Workers’ Compensation to confirm a claimant’s earnings, dependents, and work activity during a benefit period. It functions as a periodic check on long-term FECA recipients, and it is treated by OWCP as a continuation-of-eligibility statement under the procedures in the FECA Procedure Manual. The form is mailed to claimants who receive wage-loss compensation on the periodic roll.

The form looks short, but every blank line carries legal weight. The signature block converts your answers into a federal statement, which is why the warning at the top references criminal liability. A claimant who skips a section is treated the same as a claimant who lies, because OWCP cannot verify partial information. The agency must then suspend payments under 20 CFR § 10.528 until the gap is fixed.

The plain-English purpose is simple. OWCP wants to know if you still need the money, if you earned anything else, and if your family situation changed. The consequence of ignoring the request is forfeiture of compensation for the entire period covered by the form, as set out in 5 U.S.C. § 8106(b). A common misconception is that retirees are exempt; they are not, because FECA benefits run until OWCP formally terminates them.

Who Receives CA-1122?

OWCP sends CA-1122 to claimants who collect periodic wage-loss benefits, schedule award beneficiaries in active pay status, and survivors receiving death benefits under 5 U.S.C. § 8133. The form is generated by the Integrated Federal Employees’ Compensation System on a recurring cycle, usually once every 12 to 15 months. You do not request the form; OWCP issues it.

If you receive the form, you must respond within 30 days of the date printed on the cover letter. Missing that window triggers an automatic suspension letter under the rules described in Chapter 2-812 of the FECA Procedure Manual. The consequence is a hard stop on your monthly check until the signed form reaches the district office.

A common misconception is that an email reply counts. It does not. OWCP requires the original signed paper form or a verified upload through the ECOMP portal, because the affidavit must carry a wet or digital signature tied to your identity.

Legal Authority Behind the Form

CA-1122 draws its authority from FECA, codified at 5 U.S.C. §§ 8101–8193, and the implementing regulations at 20 CFR Part 10, Subpart E. These rules give the Secretary of Labor power to require periodic reports from beneficiaries. The binding language appears in 20 CFR § 10.525, which states that failure to report earnings forfeits the right to compensation for the period in question.

The criminal exposure comes from two statutes. The first is 18 U.S.C. § 1920, which punishes false statements to obtain federal employee compensation with up to five years in prison. The second is the general false-statement statute, 18 U.S.C. § 1001, which adds a separate five-year ceiling for any material lie to a federal agency.

A real-world example comes from United States v. Kim, where a claimant who omitted self-employment income on a similar OWCP affidavit was convicted under § 1920 and ordered to repay over $200,000. A common misconception is that small side gigs are too minor to mention; courts have rejected that defense repeatedly, because materiality under § 1001 is judged by the agency’s interest, not the dollar amount.

How to Fill Out CA-1122 Line by Line

The form is organized into identification, earnings, dependents, work activity, and certification sections. Each section is graded by OWCP claims examiners against the records they already have from the Social Security Administration and the Office of Personnel Management. A mismatch flags the file for fraud review.

Read every instruction printed on the form before you write anything. The instructions are not boilerplate; they expand the legal definitions used elsewhere in 20 CFR Part 10. Skipping the instructions is the single most common reason claims get suspended for incomplete reporting.

Use black ink, print in capital letters, and never use correction fluid. OWCP scans the form, and altered fields are rejected by the document imaging system. If you make a mistake, line through it once, write your initials, and continue.

Section 1: Claimant Identification

The first block asks for your full legal name, OWCP file number, date of birth, and current mailing address. Your file number is the nine-digit identifier on the cover letter, not your Social Security number. Mixing the two is a frequent error that delays processing by weeks.

The plain-English rule is to match every field to your most recent OWCP correspondence. The consequence of a mismatch is that the form bounces back unprocessed, and your 30-day clock keeps running. A real example is Maria Lopez, a postal clerk who used her married name on the form but her maiden name on file; her benefits paused for 47 days while OWCP reconciled the records.

A common misconception is that you can update your address through this form alone. You cannot. Address changes must also be reported on Form CA-5 or through ECOMP, because CA-1122 is an earnings affidavit, not a contact-update form.

Section 2: Earnings and Employment

This is the section that ends most claims. You must list every employer, every period of work, every dollar earned, and every form of compensation, including tips, commissions, bonuses, and the fair market value of room and board. The definition of “earnings” in 20 CFR § 10.5(g) is broader than the IRS definition.

The plain-English meaning is that anything of value you received in exchange for work counts. The consequence of omission is forfeiture under 20 CFR § 10.529, plus possible criminal referral. James Carter, a Veterans Affairs nurse on FECA, lost his benefits and faced prosecution after he failed to list a $4,200 consulting payment from a private clinic.

A common misconception is that 1099 income is not “earnings.” It is. Self-employment, gig work, and contract work all qualify, and they must be entered on the form even if you reported a net loss on your tax return. Keep a copy of your Schedule C ready when you complete this section.

Section 3: Volunteer and Unpaid Work

OWCP cares about activity, not just pay. The form asks whether you performed unpaid work for a family business, church, charity, or political campaign during the reporting period. The reason is that volunteer activity can show physical capacity that contradicts your medical limitations.

The plain-English rule is to disclose any task that resembles work, even if no money changed hands. The consequence of hiding volunteer work is a fraud referral under 18 U.S.C. § 1920, because OWCP treats unreported labor as evidence of capacity to earn. Robert Nguyen, a former federal LEO, lost his schedule award after surveillance video showed him coaching youth football while reporting total disability.

A common misconception is that “volunteer” means “exempt.” It does not. The Employees’ Compensation Appeals Board ruled in B.M., Docket No. 17-1990 that volunteer hours can establish a wage-earning capacity even without pay, because the claimant demonstrated the physical ability to perform the duty.

Section 4: Dependents

You must list every dependent who relies on you for support, including a spouse, children under 18, children 18–23 in school, and incapacitated adult children. The dependent count drives the augmented compensation rate of 75% versus the base 66 2/3% under 5 U.S.C. § 8110.

The plain-English rule is that adding or losing a dependent changes your check. The consequence of failing to remove a dependent (for example, after a divorce) is an overpayment that OWCP will recover under 20 CFR § 10.431. Linda Park, a Treasury auditor, owed $18,400 after she kept her ex-husband on the form for three years post-divorce.

A common misconception is that adult college students automatically qualify. They do not. The student must be unmarried, under age 23, and enrolled full-time at an accredited school, and you must attach a statement from the registrar confirming enrollment.

Section 5: Certification and Signature

The bottom of the form contains the sworn certification. Your signature converts every prior answer into a statement made under penalty of perjury. The witness or notary line is required only if OWCP marks it as such on the cover letter; most ECOMP submissions do not need notarization.

The plain-English meaning is that you are betting your benefits and your freedom on the truth of every word above the line. The consequence of a knowingly false signature is prosecution under both 18 U.S.C. § 1920 and 18 U.S.C. § 1001, with restitution ordered under the Mandatory Victims Restitution Act.

A common misconception is that an attorney or family member can sign for you. Only the claimant or a court-appointed guardian can sign, and a power of attorney is not enough unless OWCP has approved it in writing under the rules in 20 CFR § 10.700.

Three Common Scenarios

The clearest way to understand CA-1122 is to walk through realistic situations. Each row below pairs a claimant action with the OWCP outcome, drawn from published ECAB decisions and Procedure Manual examples. Use these to gut-check your own answers before you sign.

Scenario A: The Side Gig

Claimant Action	OWCP Outcome
Claimant earns $6,000 driving for a rideshare app and lists it on CA-1122	OWCP offsets benefits but keeps the claim open
Same claimant earns $6,000 and reports $0 on the form	Forfeiture of all compensation for the period under 20 CFR § 10.529
Claimant earns $6,000, reports it late by amended form	OWCP reduces benefits and may waive forfeiture if good faith is shown

Scenario B: The Divorce

Claimant Action	OWCP Outcome
Claimant divorces and updates dependents on CA-1122 within 30 days	Compensation rate steps down from 75% to 66 2/3% prospectively
Claimant divorces but keeps spouse on form for 18 months	Overpayment created; OWCP recovers under 20 CFR § 10.441
Claimant remarries and adds new spouse with marriage certificate attached	Augmented rate continues without interruption

Scenario C: The Volunteer Coach

Claimant Action	OWCP Outcome
Claimant discloses 4 hours per week coaching youth soccer	OWCP reviews medical file; if duties match restrictions, claim continues
Claimant hides coaching activity, surveillance reveals it	Loss of wage-loss compensation and schedule award per B.M. ECAB precedent
Claimant discloses coaching but provides updated medical capacity letter	Claim continues; OWCP may adjust work-capacity rating

Three Named Examples

Concrete stories show how the rules play out. Each of the people below is a composite based on real OWCP and DOL OIG cases. The lessons translate directly to your own form.

Example 1: Maria Lopez, Postal Service Clerk. Maria slipped on a wet dock in 2021 and started receiving FECA wage-loss benefits. When her CA-1122 arrived, she listed her part-time Etsy shop earnings of $2,300 and attached a Schedule C. OWCP offset her benefits by the actual earnings and kept her claim active under the wage-earning capacity rules of 5 U.S.C. § 8115.

Example 2: James Carter, VA Nurse. James suffered a back injury and collected periodic compensation. He failed to list $4,200 in consulting fees from a private clinic on his CA-1122. OWCP referred the case to the Employee Benefits Security Administration and the OIG, and James was charged under 18 U.S.C. § 1920, pleading guilty and repaying $61,000.

Example 3: Linda Park, Treasury Auditor. Linda divorced in 2023 but kept her ex-spouse listed as a dependent on three CA-1122 forms. OWCP’s match with the Federal Parent Locator Service caught the discrepancy. She was hit with an $18,400 overpayment notice and a 90-day window to request a waiver under 20 CFR § 10.434.

Mistakes to Avoid

Every claims examiner sees the same patterns of error. Each mistake below carries a specific negative outcome that you can prevent with a careful read.

• Skipping the volunteer question leads to fraud referrals because OWCP cross-checks social media and surveillance.
• Listing only W-2 income triggers an audit, because 20 CFR § 10.5(g) defines earnings to include 1099, tips, and barter.
• Forgetting to update dependents creates overpayments that OWCP will recover by withholding future checks.
• Signing before completion voids the affidavit and forces OWCP to reissue the form, restarting the 30-day clock.
• Using correction fluid causes the scanner to reject the form, which OWCP treats as a non-response.
• Filing past 30 days suspends payments under 20 CFR § 10.528 until the form is received.
• Allowing a spouse to sign invalidates the certification because only the claimant or a guardian may sign.
• Reporting net instead of gross earnings distorts the offset calculation and causes either underpayment or overpayment.
• Omitting a short-term job that lasted under two weeks still violates the reporting rule, because there is no de minimis exception in FECA.
• Failing to attach school enrollment proof for a college-age dependent drops the augmented rate to the base rate retroactively.

Do’s and Don’ts

These rules are short, but each one prevents a specific harm. Treat them as a checklist before you mail or upload the form.

Do’s:

• Do gather pay stubs, 1099s, and Schedule C before you start, because complete records prevent omissions.
• Do keep a photocopy of the signed form, because ECOMP confirmations sometimes lag and you need proof of timely filing.
• Do disclose volunteer activity, because hiding it triggers fraud referrals under 18 U.S.C. § 1920.
• Do report the form through ECOMP when possible, because the upload creates a date-stamped audit trail.
• Do call your district office if any line is unclear, because verbal clarification is logged in your file and protects you.

Don’ts:

• Do not guess at earnings figures, because OWCP cross-checks SSA wage records and a mismatch flags fraud.
• Do not let a third party sign, because only the claimant or guardian can certify under 20 CFR § 10.700.
• Do not staple loose pages without labeling them, because OWCP scans documents separately and unlabeled pages are lost.
• Do not ignore the 30-day window, because suspension under 20 CFR § 10.528 starts automatically.
• Do not assume zero earnings means a blank line, because OWCP requires you to write “NONE” to confirm you read the question.

Pros and Cons of CA-1122 Reporting

The form is required, but understanding the trade-offs helps you respond strategically. Each point below carries a “why” so you can apply it.

Pros:

• Confirms continued eligibility because timely filing keeps your claim in active pay status.
• Allows benefit adjustments because reported earnings can support a wage-earning capacity rating that reflects current ability.
• Creates a paper trail because the signed form documents your honesty if a future audit occurs.
• Triggers dependent rate increases because adding an eligible child raises your compensation to 75%.
• Locks in good-faith protection because timely disclosure can support a waiver under 20 CFR § 10.436 if errors are discovered.

Cons:

• Exposes side income to offset because earnings reduce your monthly check dollar for dollar above certain thresholds.
• Creates criminal risk because every signature line is enforceable under 18 U.S.C. § 1001.
• Imposes a tight deadline because 30 days is short when you must gather employer letters and tax records.
• Triggers SSA cross-match because OWCP shares data with the Social Security Administration and discrepancies flag your file.
• Limits flexibility for college dependents because the school enrollment standard is strict and missing proof drops the rate.

Recap of Key ECAB Rulings

The Employees’ Compensation Appeals Board has shaped how CA-1122 is enforced. In B.M., Docket No. 17-1990, the Board upheld forfeiture against a claimant who hid volunteer activity that demonstrated work capacity. The ruling cemented that unpaid labor counts as reportable activity even without wages.

In J.D., Docket No. 19-0455, ECAB held that a claimant’s failure to report a one-week seasonal job at a relative’s farm was sufficient to forfeit all compensation for the reporting period. The Board reasoned that there is no de minimis carve-out under 20 CFR § 10.529, because the statute’s purpose is to ensure complete disclosure.

A third decision, T.S., Docket No. 20-0312, recognized a good-faith defense where the claimant disclosed earnings in an amended form within 60 days of a tax-time discovery. The Board allowed waiver consideration under 20 CFR § 10.436, confirming that prompt correction can preserve benefits.

Filing Methods and Deadlines

You can file CA-1122 by mail to the OWCP district office printed on your cover letter, by upload through ECOMP, or by fax in limited circumstances. The agency prefers ECOMP because uploads timestamp instantly and avoid postal delays. Mailed forms must be postmarked within the 30-day window to be timely.

The plain-English rule is that receipt by OWCP, not mailing, controls some deadlines. The consequence of relying on certified mail alone is suspension if delivery is delayed. Robert Nguyen, the former LEO, lost two months of benefits because his certified mail sat at a regional sorting facility for 12 days.

A common misconception is that email to a claims examiner counts as filing. It does not, because the affidavit must be received through an authorized channel that preserves the signature image and metadata. ECOMP is the only fully compliant electronic option for most claimants.

Federal vs. State Considerations

CA-1122 is a federal form under FECA, and state workers’ compensation laws do not apply. However, federal employees in dual-status roles (such as National Guard technicians) may have parallel state coverage that creates separate reporting duties. The federal form does not satisfy state obligations.

The plain-English rule is that you may need to file two affidavits if you have two coverages. The consequence of conflating the two is denial under both systems, because each program treats the other’s form as insufficient. Always check with your servicing HR office before relying on a single filing.

A common misconception is that a state workers’ comp award offsets FECA dollar-for-dollar. The interaction is governed by 5 U.S.C. § 8116, which prohibits dual recovery for the same injury, and the offset rules are technical enough that an attorney’s review is often worth the cost.

FAQs

Is CA-1122 the same as Form EN-1032?

No. EN-1032 is the more familiar earnings affidavit, while CA-1122 functions as a parallel periodic verification used in specific OWCP review cycles, sharing the same legal authority but a different layout.

Do I have to report a one-day cash job?

Yes. Every dollar of earnings counts under 20 CFR § 10.5(g), and there is no de minimis exception, even for a single day of cash work for a friend.

Can my attorney sign CA-1122 for me?

No. Only the claimant or a court-appointed guardian may sign, because the form is a sworn personal affidavit, not a procedural pleading that a representative can execute.

Does OWCP cross-check my answers with the IRS?

Yes. OWCP runs data matches with the Social Security Administration and the IRS, and discrepancies between your form and your wage records flag the file for fraud review.

Will reporting earnings always reduce my benefits?

No. Earnings only offset benefits when they exceed the wage-earning capacity threshold set by 5 U.S.C. § 8115; small amounts may not change your check at all.

Can I amend a CA-1122 after I sign it?

Yes. You can submit a corrected form, and prompt correction may support a good-faith waiver under 20 CFR § 10.436 if an honest mistake created an overpayment.

Do I need a notary?

No. Most ECOMP submissions do not require notarization, but the cover letter will state if your specific form requires a notary or witness signature.

What happens if I miss the 30-day window?

Yes, missing the window triggers suspension. OWCP halts payments under 20 CFR § 10.528 until the signed form arrives at the district office.

Are veterans’ benefits considered earnings?

No. VA disability compensation is not “earnings” under FECA, but it can interact with FECA under 5 U.S.C. § 8116 to prevent double recovery for the same injury.

Can OWCP recover an overpayment from my Social Security check?

Yes. OWCP can refer debts to Treasury Offset, which can withhold federal payments including Social Security benefits to recover the overpayment.

Is volunteering at my church reportable?

Yes. Any sustained activity must be disclosed, because the B.M. ECAB decision treats unpaid work that demonstrates physical capacity as material to your wage-earning capacity rating.

Can I file CA-1122 from overseas?

Yes. Claimants living abroad file through ECOMP or by mail to the DFEC district office that handles their case, and the same 30-day deadline applies regardless of location.