Claim for Compensation by a Dependent Information Reports

OMB Control No: 1240-0013	ICR Reference No: 202604-1240-003
Status: Received in OIRA	Previous ICR Reference No: 202302-1240-003
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Claim for Compensation by a Dependent Information Reports
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 04/28/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	06/30/2026
Responses	1,241	1,241
Time Burden (Hours)	1,063	1,063
Cost Burden (Dollars)	730	556

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Abstract: The forms included in this information collection are used to request information for entitlement to claim benefits under the Federal Employees’ Compensation from federal employees, as well as their dependents or survivors, to prove continued eligibility for benefits, to show entitlement to remaining compensation payments of a deceased employee, and to show dependency.

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Authorizing Statute(s): US Code: 5 USC 8145 Name of Law: Federal Employees' Compensation Act    US Code: 5 USC 8124 Name of Law: Federal Employees' Compensation Act    US Code: 5 USC 8110 Name of Law: Federal Employees' Compensation Act    US Code: 5 USC 8149 Name of Law: Federal Employees' Compensation Act

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 4968	02/03/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 22863	04/28/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title Form No. Form Name Claim for Compensation by a Dependent Information Reports CA-5, CA-5b, CA-1031, CA-1074 Claim for Compensation by Surviving Spouse and/or Children ,   Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandchildren ,   Letter to Dependents to Verify Claimant Support ,   Letter to Parents in Death Claim Development

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,241	1,241	0	0	0	0
Annual Time Burden (Hours)	1,063	1,063	0	0	0	0
Annual Cost Burden (Dollars)	730	556	0	0	174	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $30,156

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Pamela Hamai 415 241-3350 [email protected]

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
		(a) It is necessary for the proper performance of agency functions;
		(b) It avoids unnecessary duplication;
		(c) It reduces burden on small entities;
		(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
		(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
		(f) It indicates the retention periods for recordkeeping requirements;
		(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
			(i) Why the information is being collected;
			(ii) Use of information;
			(iii) Burden estimate;
			(iv) Nature of response (voluntary, required for a benefit, or mandatory);
			(v) Nature and extent of confidentiality; and
			(vi) Need to display currently valid OMB control number;
		(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
		(i) It uses effective and efficient statistical survey methodology (if applicable); and
		(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date: 04/28/2026

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