Information Collection

Claim for Compensation by a Dependent Information Reports

IC 13841 under ICR 201302-1240-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 a Dependent Information Reports Form and Instruction
StudentDependency-revised january 2013.rtf Other-Letter
deathcompdue revised january 2013.rtf Other-Letter
CA-5 Claim for Compensaion by Widow, Widower, and/or Children CA-5 final 5-7-2013.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction
CA-1031 Claimant Support of Dependent ca-1031 revised 1240 revised January 2013.rtf www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form
CA-5B Claim for Compensation by Parents, Brothers, Sisters, Gr CA-5b final 5-7-2013.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction
CA-1074 Request for Clarification of CA-5b ca-1074 revised january 2013.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 a Dependent 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 10.410 20 CFR 10.413 20 CFR 10.7 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 final 5-7-2013.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 revised January 2013.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 final 5-7-2013.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 january 2013.rtf	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Printable Only
Other-Letter			StudentDependency-revised january 2013.rtf		No		Paper Only
Other-Letter			deathcompdue revised january 2013.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: 2,920	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	2,920	1,562	1,358
Annual IC Time Burden (Hours)	1,571	701	870
Annual IC Cost Burden (Dollars)	1,431	793	638

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.