Information Collection

Claim for Compensation by a Dependent Information Reports

IC 13841 under ICR 202008-1240-047 · 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⚠️ Notice: This information collection may be referencing outdated material.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
1240-0013 Death Comp Due.docx Other-
1240-0013 Letter of Student Dependency.docx Other-
CA-5 Claim for Compensation by Surviving Spouse and/or Childr 1240-0013 Claim for Comp by Surviving Spouse and or Children (CA-5).pdf www.dol.gov/sites/dolgov/files/owcp/regs/compliance/ca-5.pdf Form and Instruction
CA-5b Claim for Compensation by Parents, Brothers, Sisters, Gr 1240-0013 Claim for Comp by Parents Brothers Sisters Grandparents or Grandchildren (CA5b).pdf www.dol.gov/sites/dolgov/files/owcp/regs/compliance/ca-5b.pdf Form and Instruction
CA-1031 Letter to Dependents to Verify Claimant Support 1240-0013 Letter to Dependents to Verify Claimant Support (CA-1031).pdf www.dol.gov/sites/dolgov/files/owcp/regs/compliance/ca-1031.pdf Form
CA-1074 Letter to Parents in Death Claim Development 1240-0013 Letter to Parents in Death Claim Development (CA-1074).pdf www.dol.gov/sites/dolgov/files/owcp/regs/compliance/ca-1074.pdf 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 10.417 20 CFR 10.105 20 CFR 10.535 20 CFR 10.537 20 CFR 10.7 20 CFR 10.410 20 CFR 10.413

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-			1240-0013 Death Comp Due.docx		No		Paper Only
Other-			1240-0013 Letter of Student Dependency.docx		No		Paper Only
Form and Instruction	CA-5	Claim for Compensation by Surviving Spouse and/or Children	1240-0013 Claim for Comp by Surviving Spouse and or Children (CA-5).pdf	https://www.dol.gov/sites/dolgov/files/owcp/regs/compliance/ca-5.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CA-5b	Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandchildren	1240-0013 Claim for Comp by Parents Brothers Sisters Grandparents or Grandchildren (CA5b).pdf	https://www.dol.gov/sites/dolgov/files/owcp/regs/compliance/ca-5b.pdf	Yes	Yes	Fillable Fileable
Form	CA-1031	Letter to Dependents to Verify Claimant Support	1240-0013 Letter to Dependents to Verify Claimant Support (CA-1031).pdf	https://www.dol.gov/sites/dolgov/files/owcp/regs/compliance/ca-1031.pdf	Yes	Yes	Printable Only
Form	CA-1074	Letter to Parents in Death Claim Development	1240-0013 Letter to Parents in Death Claim Development (CA-1074).pdf	https://www.dol.gov/sites/dolgov/files/owcp/regs/compliance/ca-1074.pdf	Yes	Yes	Printable Only

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title: DOL/GOVT-1	FR Citation: 81 FR 47418

Number of Respondents: 933	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	933	933
Annual IC Time Burden (Hours)	800	800
Annual IC Cost Burden (Dollars)	541	541

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.