Information Collection

Claim for Continuance of Compensation

IC 13838 under ICR 201003-1240-015 · OMB 1240-0015.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0015 can be found here:

Documents and Forms

Document Name Document Type
Form CA-12 Claim for Continuance of Compensation Form
CA-12 Claim for Continuance of Compensation Under the Federal ca-12.pdf www.dol.gov/esa/regs/compliance/owcp/ca-12.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Claim for Continuance of Compensation	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 10.126

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CA-12	Claim for Continuance of Compensation Under the Federal Employees' Compensation Act	ca-12.pdf	http://www.dol.gov/esa/regs/compliance/owcp/ca-12.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title: DOL/GOVT-1	FR Citation: 67 FR 16817

Number of Respondents: 4,850	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	4,850	-600	5,450
Annual IC Time Burden (Hours)	403	-51	454
Annual IC Cost Burden (Dollars)	1,988	-12	2,000

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.