Fillable Form CA-7b
CA-7b is a form that will provide an estimate of the amount of your leave buy back (LBB) by the DOL and will be forwarded to the payroll provider.
What is Form CA-7b?
Form CA-7b, Leave Buy Back (LBB) Worksheet/Certification and Election, is a U.S. Department of Labor form that will provide an estimated amount of an employee’s leave buy back. Leave buy back means that eligible employees may receive payment at their regular salary rate in exchange for up to 80 unused leave hours.
If your Workers’ Compensation claim was granted, and you used annual and/or sick leave during periods of disability due to your injury or illness (and you presented sufficient medical paperwork that supports your leave dates), you may be eligible for a leave buy back. This will change the leave used to Leave Without Pay and the annual and/or sick leave will be available for your use again.
Form CA 7b is intended to accompany Form CA-7, Claim for Compensation, when the employee is claiming leave buy back.
When you take sick or annual leave to cover an injury-related absence from work, you may choose to be compensated instead. If you have no eligible dependents, compensation is paid at 2/3 of your base pay; if you have one or more dependents, compensation is paid at 3/4 of your base pay. In order for leave to be reinstated, you must reimburse the agency the difference between the compensation entitlement and the total amount of leave paid by the agency.
The CA-7b Form will calculate the total amount owed to repurchase your leave and will be forwarded to the payroll provider, the Defense Finance Accounting Service (DFAS). When you return the CA 7b Form, you will be informed to get an estimate of how much your leave buy back will cost you. At this point, you’ll be given the choice to continue with the leave buy back or to cancel. You’ll be asked to sign Form CA7b, confirming your decision.
You must make your decision within 30 days of the date you are notified of your estimated cost. After that time, you will be notified by the Defense Finance Accounting Service (DFAS) that you do not desire to buy back your leave, and no further action will be taken. However, your documentation will be sent to the Department of Labor for approval if you choose to proceed. Keep in mind that if you choose to discontinue the process, you would lose any future rights to leave buy back compensation for that time period.
How to fill out Form CA-7b?
Using PDFQuick, you can electronically fill out and download a PDF copy of the CA7b Form in minutes. Fill it out by following the instructions below.
Employee Statement
For completion of the employee.
Item A
Enter your full name following the format: Last Name, First Name, Middle Initial.
Item B
Enter your Office of Workers’ Compensation Program (OWCP) file number.
Item C
Enter your Social Security Number (SSN).
Item D
Enter the period for which compensation is claimed to repurchase leave, following the format: From: MM/DD/YYYY and To: MM/DD/YYYY.
Part I – Agency Estimate of FECA Entitlement
For completion of the agency.
Item A
Enter all three pay rate types and effective dates, if applicable. Choose the greatest amount of the three and enter the amount and effective date (following the format: MM/DD/YYYY) in Line 1. A recurrent pay rate should only be used if:
For unusual situations, refer to Payrate Desk Aid.
Item B
If the employee works a regular schedule, enter the differentials earned weekly. If an irregular schedule, enter the total amount earned for the year prior to the date in Line 1 divided by the number of weeks worked in that year.
Refer to Payrate Desk Aid for guidance on inclusions and exclusions. If in doubt, consult a Claims Examiner.
Item C
Add lines 1 through 5 and enter the sum in Line 6.
Item D
Circle the appropriate rate. You may select:
Dependents include spouse, children under 18 living with or supported by the employee, children under 23 in school full time, children over 18 incapable of self-support, and parents wholly supported by the employee.
Item E
Enter the total hours claimed from Form CA-7a, Time Analysis Form.
Item F
Enter the total hours in the employee’s normal workweek.
Item G
Use this formula to calculate the estimate of Federal Employees’ Compensation Act (FECA) Entitlement: Enter the amount of weekly pay rate stated in Line 6 multiplied by the compensation rate stated in Line 7 multiplied by the hours stated in Line 8 divided by the hours worked per week stated in Line 9. Then, enter the result in Line 10.
Part II – Agency Certification
For completion of the agency.
Item H
Enter the total amount due to the agency to repurchase leave.
Item I
Enter the estimate of Federal Employees’ Compensation Act (FECA) Entitlement stated in Line 10.
Item J
Subtract line 11 from line 12. Enter the difference in Line 13.
Signature of Agency Official
By signing, the agency official hereby certifies that the above information is consistent with agency payroll records. The employing agency agrees to allow the employee to repurchase his or her leave. Leave records will be, or have been, changed from “Leave with Pay” to “Leave without Pay” for the period shown on the leave analysis.
The agency official further certifies that if this claim is signed by the employee, the employee has made arrangements to pay the agency the balance between the total amount the agency requires to recredit leave and the amount of the Federal Employees’ Compensation Act (FECA) Entitlement.
Affix the signature of the agency official.
Title/Position
Enter the agency official’s title or position.
Phone Number
Enter the agency official’s phone number.
Date Signed
Enter the date the agency official signed the form, following the format: MM/DD/YYYY.
Employing Agency Address for Check
Enter the complete address of the employing agency, including street and apartment or suite number, city, state or province, and ZIP or postal code.
Note: Advise the employee of the amount they owe to the agency.
Part III – Employee Claim
For completion of the employee.
Item K
Mark the box if you elect not to repurchase the leave you used at this time.
If you elect not to repurchase the leave, retain the form in the agency files.
If you elect to repurchase the leave, submit all claim documents (Form CA-7, Claim for Compensation, Form CA-7a, Time Analysis Form, and Form CA-7b) plus any medical documentation to the Office of Workers’ Compensation Program (OWCP) for processing.
Item L
Mark the box if you elect Federal Employees’ Compensation Act (FECA) compensation to repurchase leave used for medical care or disability resulting from your job-related injury or condition.
Signature of Claimant
By signing, you understand that you are responsible for paying your agency the difference between the Federal Employees’ Compensation Act (FECA) Entitlement and the amount your agency requires to restore your leave, and have done or made arrangements for this.
You understand that if your actual entitlement to FECA compensation is within 10% of the amount estimated above. The Office of Workers’ Compensation Program (OWCP) will process the leave buy back. If the pay rate used in the worksheet above is within 10% of the pay rate determined by FECA, and less than the full period claimed is approved, the OWCP will process payment for the approved period.
Affix your signature.
Date Signed
Enter the date you signed the form following the format: MM/DD/YYYY.