Information Collection

Claim for Compensation by a Dependent Information Reports

IC 13841 under ICR 202604-1240-003 · OMB 1240-0013.

Documents and Forms

Document Name Document Type
Form CA-5 Claim for Compensation by Surviving Spouse and/or Children Claim for Compensation by a Dependent Information Reports Form and Instruction
Form CA-5b Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandchildren Claim for Compensation by a Dependent Information Reports Form and Instruction
Form CA-1031 Letter to Dependents to Verify Claimant Support Claim for Compensation by a Dependent Information Reports Form
Form CA-1074 Letter to Parents in Death Claim Development Claim for Compensation by a Dependent Information Reports Form
Comp Due At Death letter.docx Other-
StudentDependency.rtf Other-
CA-5 Claim for Compensation by Surviving Spouse and/or Childr 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 ca-5b.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 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 10.535 20 CFR 10.537 20 CFR 10.7 20 CFR 10.410 20 CFR 10.413 20 CFR 10.417 20 CFR 10.105

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-			Comp Due At Death letter.docx		No		Paper Only
Other-			StudentDependency.rtf		Yes	Yes	Paper Only
Form and Instruction	CA-5	Claim for Compensation 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	ca-5b.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	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: 1,241	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 71 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,241	0	1,241
Annual IC Time Burden (Hours)	1,063	0	1,063
Annual IC Cost Burden (Dollars)	730	174	556

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.

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