OMB control number

Claim for Continuance of Compensation (CA-12)

OMB 1240-0015 · DOL/OWCP.

OMB 1240-0015

This form is used to obtain information from eligible survivors receiving death benefits for an extended period of time. This information is necessary to ensure that compensation being paid is accurate.

The latest form for Claim for Continuance of Compensation (CA-12) expires 2027-01-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CA-12 Claim for Continuance of Compensation Form and Instruction
60-day FRN (1240-0015) 8.7.23.pdf Supplementary Document
dol govt - 1.pdf Supplementary Document
5 USC 8133.pdf Supplementary Document
National Average Weekly Wage for non-supervisory workers on private non-agriculture payrolls as computed by BLS as of April 2023.pdf Supplementary Document
OPM Salary Table 2023. RUS.pdf Supplementary Document
Supporting Statement 1240-0015 2023_MN nmh clean version..docx Supporting Statement A
Claim for Continuance of Compensation Form and Instruction

All Historical Document Collections

202310-1240-001 Approved without change	Extension without change of a currently approved collection	2023-12-05
202005-1240-003	Extension without change of a currently approved collection	2020-10-16
202002-1240-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-02-21
201703-1240-005 Approved without change	Revision of a currently approved collection	2017-07-31
201402-1240-001 Approved without change	Revision of a currently approved collection	2014-06-13
201011-1240-003 Approved without change	Revision of a currently approved collection	2011-05-03
201003-1240-015 Approved without change	Extension without change of a currently approved collection	2010-03-12