Information Collection

Claim for Compensation by Dependents Information Reports

IC 13841 under ICR 201004-1240-013 · 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⚠️ Notice: This information collection may be referencing outdated material.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
StudentDependency-revised 1240.rtf Other-Letter
deathcompdue revised 1240.rtf Other-Letter
CA-5 Claim for Compensaion by Widow, Widower, and/or Children CA-5.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction
CA-1031 Claimant Support of Dependent ca-1031 revised 1240.rtf www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form
CA-5B Claim for Compensation by Parents, Brothers, Sisters, Gr CA-5b - 1240-revised.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction
CA-1074 Request for Clarification of CA-5b ca-1074 revised 1240.rtf www.dol.gov/owcp/dfec/regs/compliance/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 10.410 20 CFR 10.413 20 CFR 10.417 20 CFR 10.535 20 CFR 10.537 20 CFR 10.105

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/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable
Form	CA-1031	Claimant Support of Dependent	ca-1031 revised 1240.rtf	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Printable Only
Form and Instruction	CA-5B	Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandshildren	CA-5b - 1240-revised.pdf	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable
Form	CA-1074	Request for Clarification of CA-5b	ca-1074 revised 1240.rtf	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Printable Only
Other-Letter			StudentDependency-revised 1240.rtf		No		Paper Only
Other-Letter			deathcompdue revised 1240.rtf		No		Paper Only

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title: DOL/GOVT-1	FR Citation: 67 FR 16826

Number of Respondents: 1,358	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,358	0	-522	1,880
Annual IC Time Burden (Hours)	870	0	-207	1,077
Annual IC Cost Burden (Dollars)	638	186	0	452

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.