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View ESA-OWCP-DLHWC's Form 1215-0160 Online 
| Agency: |
ESA-OWCP-DLHWC |
| Title: |
DLHWC (Longshore) LS-267, Claimant's Statement |
| Form Description: |
DLHWC (Longshore) LS-267, Claimant's Statement: This report is required. A surviving spouse receiving death benefits must submit this form to state their current marital status and advise whether they have remarried. It is also submitted by or on behalf of a death benefits beneficiary as a student to state and advise whether the student continues to be enrolled in school full-time. The form is used to determine continuing eligibility for compensation benefits. Failure to submit the form may result in termination or loss of compensation benefits. |
| OMB Control Number: |
1215-0160 |
| OMB Expiration Date: |
Monday, August 31, 2009
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