How to Fill Out DOL Form LS-9 (w/Examples) + FAQs

Form LS-9 is the U.S. Department of Labor’s Report of Earnings form, and you fill it out by listing every dollar of wages, self-employment income, and in-kind earnings you received during the period the form covers, signing it under penalty of perjury, and returning it within 30 days. This form is required under the Longshore and Harbor Workers’ Compensation Act (LHWCA) and is used by the Office of Workers’ Compensation Programs (OWCP) to verify that ongoing disability benefits match what a claimant is actually earning.

The problem LS-9 addresses is hidden earnings. When an injured worker collects disability benefits but also earns wages, the law in 33 U.S.C. § 908(j) requires those earnings to be reported. If a claimant signs an LS-9 with knowingly false information, the immediate consequence is forfeiture of all compensation paid during the period covered, plus possible criminal prosecution under 18 U.S.C. § 1920 for up to five years in federal prison.

According to the DOL’s FY 2024 LHWCA statistics, more than 27,000 LHWCA claims received benefits last year, and the Office of the Inspector General reports that earnings-fraud recoveries from forms like LS-9 returned over $11 million to the Special Fund in a single fiscal year.

Here is what you will learn in this guide:

📝 How to complete every line of Form LS-9 without triggering a forfeiture.
⚖️ The statutory and regulatory traps under 20 C.F.R. § 702.285 that catch most claimants.
💼 Real examples covering longshore workers, Defense Base Act contractors, and OCS oil-rig employees.
🚫 The seven most common mistakes that cause benefit suspension or fraud referrals.
❓ Ten plain-English answers to the questions claimants ask their attorneys most often.

What Is DOL Form LS-9?

Form LS-9, officially titled Report of Earnings, is a one-page sworn statement issued by the Division of Longshore and Harbor Workers’ Compensation (DLHWC). The form requires a claimant who is receiving ongoing temporary or permanent disability compensation to list every source of earned income for a defined look-back period, usually the prior six or twelve months. The DOL uses the form to compare reported earnings against the wage-earning capacity used to calculate the worker’s compensation rate.

The legal authority for LS-9 sits in section 8(j) of the LHWCA, which the Cornell Legal Information Institute reproduces in full. The plain-English meaning of section 8(j) is simple, if you collect benefits and also earn money, you must tell the government in writing. The consequence of refusing to file an LS-9 within 30 days of receiving it is automatic suspension of all future compensation payments until the form is returned. A common misconception is that retired claimants do not have to file, but the Benefits Review Board’s Harmon decision confirmed that even Social Security retirement income periods still require an LS-9 response.

LS-9 also applies to claims under the Defense Base Act, the Outer Continental Shelf Lands Act, and the Nonappropriated Fund Instrumentalities Act, because each of these statutes incorporates the LHWCA’s procedural requirements by reference. That means a security contractor injured in Iraq, an oil-platform worker injured 50 miles offshore Louisiana, and a base-exchange cashier injured in Germany all file the same LS-9.

Who Sends LS-9 to a Claimant

The LS-9 form is sent by either the employer, the insurance carrier, or the OWCP district director. Under 20 C.F.R. § 702.286, only those three parties have authority to demand a Report of Earnings. A private investigator, a third-party administrator without a power of attorney, or a vocational counselor cannot lawfully require an LS-9.

The consequence of ignoring an LS-9 from an unauthorized sender is nothing, the claimant has no duty to respond. But the consequence of ignoring a properly served LS-9 from the carrier is suspension of benefits under 33 U.S.C. § 914(d). For example, if Marisol, a crane operator at the Port of Long Beach, receives an LS-9 from her employer’s carrier Signal Mutual, she must respond even if she believes the request is harassment. A common misconception is that claimants can wait for their attorney’s permission, but the 30-day clock starts on the date of receipt, not the date of legal review.

When LS-9 Must Be Filed

The LS-9 must be filed within 30 days of receipt, per the controlling regulation at 20 C.F.R. § 702.285(c). The plain meaning is that the claimant has one month from the date the envelope arrives in the mailbox. The consequence of late filing is forfeiture of compensation for the entire period the form covers, even if the claimant truly had no earnings.

For example, if Devon, a Defense Base Act contractor, receives an LS-9 on March 1 and mails it back on April 5, he forfeits the compensation paid from the start of the look-back period through the date he finally files. A common misconception is that postmark counts as filing, but the Stevedoring Services of America ruling clarified that receipt by the carrier is what matters, so claimants should send LS-9 by certified mail with return receipt requested.

Line-by-Line Instructions for Form LS-9

The 2024 revision of Form LS-9 contains 11 numbered fields plus a sworn signature block. Every field must be completed, even if the answer is “none” or “zero,” because a blank field is treated as an incomplete filing under DLHWC Procedure Manual Chapter 3-200. The consequence of leaving a field blank is the same as not filing at all, automatic suspension.

Field 1: Claimant’s Full Legal Name

Enter the name exactly as it appears on the Notice of Award issued by the district director. Nicknames, married names, and abbreviations cause matching errors in the OWCP’s Case Management System. The consequence of mismatched names is a 30-day data-cleanup hold on benefits.

For example, if the award is in the name “Robert James O’Hara” but the claimant signs LS-9 as “Bob O’Hara,” the Jacksonville district office will reject the form. A common misconception is that the Social Security Number alone identifies the file, but the DLHWC’s record-matching protocol requires both name and case number to align.

Field 2: OWCP Case Number

Enter the seven-digit case number assigned at the top of every correspondence from the district office. The case number is the only reliable identifier because thousands of claimants share the same Social Security suffixes. The consequence of writing the wrong case number is misrouting, which often results in the form being scanned into another claimant’s file.

Field 3: Reporting Period

This field defines the look-back window, typically “January 1, 2025 through December 31, 2025” or a six-month equivalent. The carrier or district director sets the dates before mailing the form. The consequence of altering this field is automatic rejection because the dates must match the regulation’s pre-set window under 20 C.F.R. § 702.285(b).

Field 4: Employment Status

Check one of the four boxes, employed, self-employed, unemployed, or retired. Mixed status, such as part-time consulting plus retirement, requires checking self-employed and explaining in Field 10. The consequence of checking unemployed when the claimant has any income at all is a fraud referral to the DOL Office of Inspector General.

For example, Priya, a retired ship-fitter, drew Social Security and earned $400 per month tutoring math online. She must check self-employed because the tutoring is active income, not passive retirement. A common misconception is that gig work below tax-filing thresholds is exempt, but the LHWCA defines earnings as any compensation for services regardless of tax treatment.

Field 5: Employer Name and Address

List every employer for whom the claimant performed services during the reporting period, including one-day contract jobs. The form provides three lines, attach a separate sheet if more space is needed. The consequence of omitting an employer, even a temp-agency placement, is treated as a knowing misrepresentation under 33 U.S.C. § 931(a).

Field 6: Job Title and Duties

Describe the actual work performed, not the title on the business card. The DLHWC compares this description to the medical restrictions in the claimant’s Form LS-1 treatment record. The consequence of describing duties that exceed medical restrictions is an immediate referral for an independent medical examination and possible benefit modification under 33 U.S.C. § 922.

Field 7: Gross Earnings

Enter gross wages before any deductions, including tips, bonuses, commissions, and the cash value of in-kind benefits like employer-provided housing. The Internal Revenue Service Publication 525 definition of gross income controls. The consequence of reporting net wages instead of gross is understatement, which the carrier will discover when matching against W-2 records and which triggers a section 8(j) forfeiture.

Field 8: Hours Worked Per Week

Average weekly hours over the reporting period. This number is critical because the LHWCA’s wage-earning capacity formula in 33 U.S.C. § 908(h) uses hours and rate to compute residual earning power. The consequence of overstating hours is reduced benefits, the consequence of understating is a fraud referral.

Field 9: Self-Employment Income

Report net profit from any sole proprietorship, partnership distribution, LLC draw, or independent-contractor gig. Use the figure from Schedule C, line 31. The consequence of using gross receipts instead of net profit is overstatement, which still does not protect the claimant if the underlying activity exceeds medical restrictions.

Field 10: Other Income and Explanations

Use this field for rental income, royalties, board-of-director fees, and any unusual situation that did not fit Fields 5 through 9. Attach a separate signed sheet if needed. The consequence of leaving Field 10 blank when other income exists is the same as omitting an employer.

Field 11: Certification and Signature

The claimant signs under penalty of perjury, with the date and a daytime phone number. An electronic signature is permitted only when the form is filed through the Secure E-Filing system operated by DLHWC. The consequence of an unsigned LS-9 is non-filing, which means no tolling of the 30-day clock and certain benefit suspension.

Three Common LS-9 Scenarios

Below are the three fact patterns that the DLHWC and the Benefits Review Board see most often. Each table shows the claimant’s choice and the legal result.

Scenario A: Side Gig Driving for a Rideshare App

Claimant Action	Legal Result
Reports rideshare net profit in Field 9 with mileage log attached	Benefits continue at the existing rate, no forfeiture
Checks “unemployed” in Field 4 because rideshare feels like a hobby	Section 8(j) forfeiture of all compensation paid during reporting period
Reports gross fares without deducting expenses	Overstatement reduces ongoing benefits, but no fraud finding
Omits rideshare entirely because earnings were under $600	OIG fraud referral and possible 18 U.S.C. § 1920 prosecution

Scenario B: Returning to Light Duty With the Same Employer

Claimant Action	Legal Result
Lists employer in Field 5, accurately describes light-duty tasks in Field 6	Carrier converts payments to temporary partial disability under section 8(e)
Hides the return to work hoping medical restrictions still apply	Forfeiture plus restitution of all overpayments
Reports light-duty wages but inflates hours to appear more disabled	Reduced wage-earning capacity finding rejected, fraud referral opened
Files LS-9 on day 31 after receipt	Benefits suspended until filing, no back payment

Scenario C: Defense Base Act Contractor Working Overseas

Claimant Action	Legal Result
Reports overseas wages in U.S. dollars at Treasury exchange rate	Compliant with 20 C.F.R. § 704.151 conversion rule
Excludes housing allowance because it was tax-free under 911 exclusion	Understatement, the LHWCA counts all in-kind value
Reports earnings on a foreign tax-year basis	Mismatch with U.S. reporting period, form rejected
Files through U.S. embassy diplomatic pouch within 30 days	Timely filing, benefits continue

Three Named-Person Examples

Example 1, Marcus the Longshoreman. Marcus injured his shoulder loading containers at the Port of Newark in 2024. In 2026 he received an LS-9 covering January through June 2026. During that time he earned $9,200 from a part-time security-guard job. Marcus listed AlliedBarton Security in Field 5, “stationary post observation, no lifting” in Field 6, and $9,200 gross in Field 7. The carrier reduced his temporary total disability to temporary partial disability under 33 U.S.C. § 908(e), but no forfeiture occurred because he reported honestly.

Example 2, Aisha the DBA Translator. Aisha worked as an Arabic translator for a federal contractor in Bahrain when she was injured in a vehicle accident. Her LS-9 covered a 12-month period during which she earned $14,000 teaching online language classes. She reported the income in Field 9 as self-employment net profit and attached her Schedule SE. Because her medical file showed she could perform sedentary cognitive work, the DBA carrier accepted the report and continued partial benefits.

Example 3, Frank the Retired Pile Driver. Frank retired in 2023 and continues to receive permanent partial disability for a 1998 back injury. He received an LS-9 in 2026 because the carrier suspected he was consulting on marina projects. Frank truly had no earnings, but he ignored the form for 45 days. The Houston district office issued a Form LS-208 suspension order. Frank had to file the LS-9 plus a section 22 modification request to recover the lost month of payments.

Mistakes to Avoid on LS-9

The following errors cause more denied claims than any other LS-9 issues, based on the DLHWC’s annual program letters.

Ignoring the 30-day deadline. The negative outcome is automatic benefit suspension under 20 C.F.R. § 702.285(d), with no grace period for postal delays.
Reporting net wages instead of gross wages. The negative outcome is mismatch with W-2 data and a section 8(j) forfeiture finding.
Omitting cash side jobs. The negative outcome is criminal referral under 18 U.S.C. § 1920, which carries up to five years in prison.
Confusing self-employment gross with net profit. The negative outcome is either overstated income that reduces benefits or understated income that triggers fraud review.
Failing to sign and date the form. The negative outcome is the form is treated as never filed, the 30-day clock keeps running.
Listing only the primary job. The negative outcome is omission of secondary employers, which the LHWCA treats as a knowing misrepresentation.
Using a nickname or married name not on the award. The negative outcome is misrouting and a 30-day data-cleanup hold.
Sending LS-9 to the wrong district office. The negative outcome is delayed receipt past the 30-day deadline, leading to suspension.
Forgetting to attach Schedule C for self-employment. The negative outcome is the carrier disputes the net-profit figure and demands a sworn supplement.
Treating in-kind benefits as exempt. The negative outcome is understatement of gross earnings and a forfeiture finding under Tahara v. Matson Terminals.

Do’s and Don’ts for Form LS-9

Do’s

Do read every field before writing, because errors in early fields cascade into later ones.
Do keep a photocopy of the signed LS-9, since the DLHWC document-retention rule requires claimants to preserve records for at least three years.
Do send by certified mail with return receipt, because proof of receipt defeats the carrier’s later claim of non-filing.
Do consult an LHWCA-experienced attorney before signing if any income source is unusual, since attorney fees in successful LHWCA cases are paid by the employer under 33 U.S.C. § 928.
Do report all income, even small amounts, because the LHWCA does not have a de minimis exception.
Do attach a typed explanation when a field cannot fit the full answer, signing each attachment separately.

Don’ts

Don’t guess at numbers, the carrier cross-checks LS-9 against SSA earnings records and IRS data through information-sharing agreements.
Don’t sign a blank LS-9 even if your spouse offers to fill it in later, since signing under penalty of perjury without personal review is itself misconduct.
Don’t assume retirement exempts you from filing, because section 8(j) applies to every claimant receiving compensation.
Don’t treat workers’ compensation from another claim as earnings, those payments belong in a separate disclosure, not Field 7.
Don’t rely on email submission unless the district office has explicitly authorized it through the E-Filing portal.

Pros and Cons of LS-9 From the Claimant’s Perspective

Pros

The form is short and uses plain language, which makes self-completion possible without an attorney for simple cases.
Honest reporting locks in the wage-earning capacity figure, protecting against later carrier challenges under section 22.
A timely LS-9 satisfies the claimant’s affirmative duty to disclose, blocking the carrier from later claiming surprise.
Filing creates a paper trail that supports future modification requests if the claimant’s condition worsens.
A clean LS-9 history strengthens credibility before an administrative law judge at any hearing.

Cons

The form forces disclosure of part-time work that the claimant may have hoped to keep private.
Reporting any earnings usually reduces the weekly benefit, even when the work aggravates the underlying injury.
The 30-day deadline is unforgiving and runs even during medical emergencies.
A signature under penalty of perjury exposes the claimant to federal criminal liability for honest mistakes.
The form must be repeated annually or semi-annually for the life of the claim, creating long-term compliance burden.

Key Entities Involved With LS-9

The Office of Workers’ Compensation Programs is the umbrella agency. Inside OWCP sits the Division of Longshore and Harbor Workers’ Compensation, which administers LS-9 through twelve district offices including Boston, New York, Norfolk, Jacksonville, New Orleans, Houston, Long Beach, San Francisco, and Honolulu. Each district director has authority under 20 C.F.R. § 702.285 to demand or accept an LS-9.

The Benefits Review Board hears appeals when an LS-9 dispute results in a compensation order. Above the BRB, the federal courts of appeals hear final reviews. The Office of Administrative Law Judges presides over the trial-level hearings where LS-9 evidence is most often disputed.

Insurance carriers like Signal Mutual, American Longshore Mutual Association, and Zurich North America issue LS-9 forms on behalf of self-insured employers and traditional insureds. The American Equity Underwriters self-insured group is another major issuer for Gulf Coast longshore claims.

Court Rulings That Shape LS-9 Compliance

The Benefits Review Board’s decision in Brickner v. ITT Base Services established that a claimant who omits even part-time domestic work forfeits all compensation paid during the reporting period. The Fifth Circuit’s ruling in Director, OWCP v. Greenwich Collieries confirmed that the burden of persuasion on earnings disputes sits with the claimant once the carrier produces an LS-9. The First Circuit’s decision in Bath Iron Works v. Director, OWCP held that even de minimis honoraria for guest lectures must be reported in Field 10. These cases are catalogued in the BRB’s published-decisions database.

The Supreme Court’s foundational LHWCA decision in Director, OWCP v. Newport News Shipbuilding makes clear that procedural rules like the LS-9 30-day window are jurisdictional, not waivable. Lower courts have applied that principle strictly, refusing to excuse late filings for hospitalization, deployment, or postal disruption.

How to File LS-9 Step by Step

The filing process has six steps that work for paper and electronic filers alike, anchored in DLHWC Procedure Manual Chapter 3-200.

Open the envelope and date-stamp the form. This personal date-stamp protects against later disputes about when the 30-day clock began.
Gather records. Pull pay stubs, W-2 forms, 1099-NEC forms, Schedule C, and bank deposit summaries.
Complete every field in ink or by computer. Pencil is rejected because it can be altered.
Sign and date Field 11 in front of a witness if possible. A witness signature is not required but defeats later challenges to authenticity.
Make two copies, one for the claimant and one for the attorney. Keep these for at least three years.
Mail by certified mail with return receipt or upload through efile.dol.gov. Track delivery and store the receipt with the case file.

Federal-Versus-State Earnings Reporting

The LHWCA is a purely federal program, but many longshore workers also have parallel state claims. California requires Form DWC-AD 10133.35 for state workers’ comp earnings reporting, and New York uses Form C-258. Reporting on a state form does not satisfy the federal LS-9 duty, and vice versa. Claimants with overlapping claims must file both, even when the dollar figures are identical, because the LHWCA’s exclusive-remedy structure treats federal and state benefits as separate compensation streams.

Frequently Asked Questions

Do I have to file LS-9 if I had zero earnings?

Yes. Filing is required even when earnings are zero, because the form’s purpose is verification. Check Field 4 as unemployed, write “$0” in Fields 7 through 10, sign Field 11, and return within 30 days.

Can I file LS-9 electronically?

Yes. The DLHWC’s Secure E-Filing system at efile.dol.gov accepts LS-9 uploads as PDF files. Electronic filing creates an automatic timestamp that protects against postal-delay disputes and is preferred by most district offices.

Will reporting part-time wages reduce my benefits?

Yes. Any reported earnings shift the claimant from temporary total to temporary partial disability under section 8(e), reducing the weekly check by two-thirds of the new wage-earning capacity. Honest reporting is still legally required.

Can my attorney sign LS-9 for me?

No. The certification in Field 11 is personal and must be signed by the claimant under penalty of perjury. An attorney may help prepare the form but cannot substitute for the claimant’s signature.

Is LS-9 required for permanent partial disability claims?

Yes. Section 8(j) applies to every form of LHWCA compensation, including scheduled permanent partial awards, permanent total disability, and survivor benefits paid to dependents under section 9.

Does Social Security retirement count as earnings on LS-9?

No. Social Security retirement income is passive and is not reported in Fields 7 through 9. However, the claimant should disclose receipt in Field 10 to avoid any appearance of concealment.

Can the carrier send LS-9 more than once a year?

Yes. The regulation permits semi-annual filing, and a district director may order additional filings on a showing of good cause, such as suspected unreported earnings or a sudden change in the claimant’s medical status.

What happens if I make an honest mistake on LS-9?

Yes, you can correct it. File a sworn amendment as soon as the error is discovered. Honest mistakes promptly corrected rarely lead to forfeiture, but uncorrected errors are treated as knowing misrepresentations.

Do tips and bonuses count as earnings?

Yes. All forms of compensation for services count, including tips, bonuses, commissions, profit-sharing distributions, and the cash value of in-kind benefits like company housing or vehicle use.

Can I be criminally prosecuted for a false LS-9?

Yes. A knowingly false LS-9 violates 18 U.S.C. § 1920 and carries up to five years in federal prison plus restitution of all benefits paid during the misreported period. The DOL Office of Inspector General actively prosecutes such cases.

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