Information Collection

Claim for Compensation by Dependents Information Reports

IC 13841 under ICR 201003-1240-013 · OMB 1240-0013.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0013 can be found here:

Documents and Forms

Document Name Document Type
Form CA-5 Claim for Compensation by Dependents Information Reports Form and Instruction
CompensationDueAtDeath.rtf Other-Letter
StudentDependency.rtf Other-Letter
CA-5 Claim for Compensaion by Widow, Widower, and/or Children ca-5.pdf www.dol.gov/esa/regs/compliance/owcp/forms.htm Form and Instruction
CA-1031 Claimant Support of Dependent ca-1031.pdf www.dol.gov/esa/regs/compliance/owcp/forms.htm Form
CA-5B Claim for Compensation by Parents, Brothers, Sisters, Gr ca-5b.pdf www.dol.gov/esa/regs/compliance/owcp/forms.htm Form and Instruction
CA-1074 Request for Clarification of CA-5b ca-1074.pdf www.dol.gov/esa/regs/compliance/owxp/forms.htm Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Claim for Compensation by Dependents Information Reports	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 10.7 20 CFR 10.105 20 CFR 10.410 20 CFR 10.413 20 CFR 10.417 20 CFR 10.535 20 CFR 10.537

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CA-5	Claim for Compensaion by Widow, Widower, and/or Children	ca-5.pdf	http://www.dol.gov/esa/regs/compliance/owcp/forms.htm	Yes	No	Fillable Printable
Form	CA-1031	Claimant Support of Dependent	ca-1031.pdf	http://www.dol.gov/esa/regs/compliance/owcp/forms.htm	Yes	No	Printable Only
Form and Instruction	CA-5B	Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandshildren	ca-5b.pdf	http://www.dol.gov/esa/regs/compliance/owcp/forms.htm	Yes	No	Fillable Printable
Form	CA-1074	Request for Clarification of CA-5b	ca-1074.pdf	http://www.dol.gov/esa/regs/compliance/owxp/forms.htm	Yes	No	Printable Only
Other-Letter			CompensationDueAtDeath.rtf		No		Paper Only
Other-Letter			StudentDependency.rtf		No		Paper Only

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,880	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,880	0	1,880
Annual IC Time Burden (Hours)	1,077	0	1,077
Annual IC Cost Burden (Dollars)	452	452	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.