OMB control number

Claim for Compensation by a Dependent Information Reports

OMB 1240-0013 · DOL/OWCP.

OMB 1240-0013

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.

The latest form for Claim for Compensation by a Dependent Information Reports expires 2026-06-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CA-1074 Letter to Parents in Death Claim Development Form
Form CA-1031 Letter to Dependents to Verify Claimant Support Form
Form CA-5b Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandchildren Form and Instruction
Form CA-5 Claim for Compensation by Surviving Spouse and/or Children Form and Instruction
OPM Salary Table 2025-RUS.pdf Supplementary Document
Table B-8 Average hourly and weekly earnings of production and nonsupervisory employees on private nonfarm payrolls.pdf Supplementary Document
81 Fed. Reg. 47418 (July 21, 2016).pdf Supplementary Document
20 cfr 10.7 etc.docx Supplementary Document
5 usc 8110 augmented compensation for dependents.docx Supplementary Document
1240-0013 Supporting Statement -1-13-26 updated.docx Supporting Statement A
Claim for Compensation by a Dependent Information Reports Form
Claim for Compensation by a Dependent Information Reports Form
Claim for Compensation by a Dependent Information Reports Form and Instruction
Claim for Compensation by a Dependent Information Reports Form and Instruction
Claim for Compensation by a Dependent Information Reports Other-

All Historical Document Collections

202604-1240-003	Extension without change of a currently approved collection	2026-04-28
202302-1240-003 Approved with change	Extension without change of a currently approved collection	2023-05-09
202008-1240-047 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-10-20
201910-1240-002 Approved without change	Reinstatement without change of a previously approved collection	2020-04-15
201602-1240-003 Approved without change	Revision of a currently approved collection	2016-08-24
201302-1240-001 Approved without change	Revision of a currently approved collection	2013-07-01
201004-1240-013 Approved without change	Extension without change of a currently approved collection	2010-05-28
201003-1240-013 Approved without change	Extension without change of a currently approved collection	2007-03-01