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U.S. DEPARTMENT OF LibreOffice of Workers Compensation Programs Washington, D.C. 20210OMB No: 12400013 Expiration Date: xxxxxxxxFile Number:Sender (Address):Date:Phone: Date of Injury: Employee: DEP(s):To
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OMB No. 1240-0013 is a form used by federal agencies to collect information from individuals or organizations.
Certain individuals or organizations may be required to file OMB No. 1240-0013 based on specific criteria set by the issuing agency.
To fill out OMB No. 1240-0013, individuals or organizations must follow the instructions provided on the form by the issuing agency.
The purpose of OMB No. 1240-0013 is to collect specific information from individuals or organizations for regulatory or compliance reasons.
The specific information required to be reported on OMB No. 1240-0013 will be outlined on the form itself by the issuing agency.
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