Printing - FECA-PT2 - National Association of Letter Carriers

SAMPLE REQUEST FOR INFORMATION FROM CLAIMANT RE HEALTH CLUB/SPA MEMBERSHIP,
Continued
INJURED EMPLOYEE'S STATEMENT OF AVAILABLE
AND PREFERRED FACILITIES
Please provide the following information with respect to your request for payment of membership in a
health club or spa. Use a separate sheet of paper if additional space is needed.
1. Contact and list local public or government facilities suitable for the exercise routine described by your
doctor (include any available through your employing agency).
Name of Facility
Distance Charge
& Person Contacted Full Address from Home or Fee
__________________ _____________ _________
__________________ _____________ _________
__________________ _____________ _________
______
______
______
2. Contact and list local commercial (membership and/or usage fee required) facilities suitable for the
exercise routine described by your doctor.
Name of Facility
Distance Charge
& Person Contacted Full Address from Home or Fee
__________________ _____________ _________
__________________ _____________ _________
__________________ _____________ _________
______
______
______
3. From the above lists, indicate your preference)(s) for use and/or membership if OWCP authorizes
payment. If more than one is suitable, list in order of your preference. If membership in a more costly
facility is requested where a less costly local facility is also available, provide justification/explanation for
use of the more costly facility.
I hereby certify that the above information is true to the best of my knowledge. I understand that any
person who knowingly makes any false statement, misrepresentation, concealment of fact, or who
commits any act of fraud to obtain benefits provided by the Federal Employees' Compensation Act is
subject to felony criminal prosecution.
__________________________________________ ___________
Signature of Employee Date
FECA-PT2 Printed: 06/08/2010 356