Death Gratuity

Forms and Documents

Document Name	Status
Form ca-42 Death Gratuity Official Notice of Employees' Death Form and Instruction	New
Form ca-41 Death Gratuity Claim for Survivor Benefits Form and Instruction	New
Form ca-40 Death Gratuity Beneficiary Designation Form and Instruction	New
DEPARTMENT OF LABOR 1215-AB66 Emergency Submission.doc Supplementary Document	2009-08-27
dol-govt-1.doc Supplementary Document	2009-08-10
2009 opm salary table (4).pdf Supplementary Document	2009-08-10
2009 databases tables and calculators by subject 8-10-09.pdf Supplementary Document	2009-08-10
Death Gratuity Forms Supporting Statement 8-27-2009.doc Supporting Statement A	2009-08-28

IC Document Collections

IC ID	Document Title	Status
190297	Death Gratuity Official Notice of Employees' Death Form and Instruction	New
190296	Death Gratuity Claim for Survivor Benefits Form and Instruction	New
190277	Death Gratuity Beneficiary Designation Form and Instruction	New

ICR Details

OMB Control No: 1215-0206	ICR Reference No: 200908-1215-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: DOL/ESA	Agency Tracking No:
Title: Death Gratuity
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 09/28/2009
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/03/2009
	Date Received in OIRA: 08/28/2009
Terms of Clearance: Approved as revised by DOL.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2010	6 Months From Approved
Responses	2,635	0	0
Time Burden (Hours)	659	0	0
Cost Burden (Dollars)	12	0	0

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Abstract: The National Defense Authorization Act for Fiscal Year 2008, Public Law 110-181, was enacted on January 28, 2008. Section 1105 of P.L. 110-181 amended the Federal Employees’ Compensation Act (FECA) creating a new section 8102a effective upon enactment. This section establishes a new FECA death gratuity benefit of up to $100,000 for eligible beneficiaries of federal employees and Non-Appropriated Fund Instrumentality (NAFI) employees who die from injuries incurred in connection with service with an Armed Force in a contingency operation. Section 8102a also permits agencies to authorize retroactive payment of the death gratuity for employees who died on or after October 7, 2001, in service with an Armed Force in the theater of operations of Operation Enduring Freedom and Operation Iraqi Freedom. To help it exercise its responsibility to administer this benefit, the Office of Workers’ Compensation Programs (OWCP) has promulgated an interim final rule. The statute and regulations allow for employees to vary the statutory order of precedence for beneficiaries and to designate alternative recipients of this benefit. Form CA-40 requests the information necessary from the employee to accomplish this variance. Form CA-41 provides the means for those named beneficiaries and possible recipients to file claims for those benefits and requests information from such claimants so that OWCP may determine their eligibility for payment. Further, the statute and regulations require agencies to notify OWCP immediately upon the death of a covered employee. CA-42 provides the means to accomplish this notification and requests information necessary to administer any claim for benefits resulting from such a death.

Emergency Justfication: In accordance with 5 CFR 1320.13, emergency processing of this collection is requested and is essential to the mission of the agency; the agency cannot reasonably comply with the normal clearance procedures under this Part because the use of normal clearance procedures is reasonably likely to prevent or disrupt the collection of information or is reasonably likely to cause a statutory deadline to be missed. The agency has taken all practicable steps to consult with interested agencies and members of the public to minimize the burden of the collection of this information. Under 5 CFR 1320.13, it is requested that this collection be submitted and approved on an emergency basis. Under the National Defense Authorization Act for FY2008, an amendment to the FECA allows for immediate death gratuity payments to eligible survivors of Federal employees and employees of nonappropriated funded instrumentalities (NAFI) who die of injuries sustained in connection with the employee's service with an Armed Force serving in a contingency operation. While the Public Law became effective January 28, 2008, it also provides a provision in which a death gratuity may also be paid to eligible survivors of employees from certain agencies who died on or after October 7, 2001, due to injuries incurred in connection with the service of an Armed Force in the theatre of operations of Operation Enduring Freedom and Operation Iraqi Freedom. The OWCP FECA has been delegated the authority to administer the adjudication of claims and payment of the death gratuity under new section 5 U.S.C. 8102a, and has initiated a new collection with 3 distinct forms to meet stature requirements. Because of the immediate and retroactive provisions of this Law, the Agency requests that an immediate review and authorization of this collection be approved for 180 days to implement section 8102a. The agency will subsequently follow up with normal processing procedures to allow for the routine three year extension of this collection.

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Authorizing Statute(s): PL: Pub.L. 110 - 181 1105 Name of Law: National Defense Authorization Act
   US Code: 5 USC 8102a Name of Law: Amendment to the FECA, Death Gratuity
  

Citations for New Statutory Requirements: PL: Pub.L. 110 - 181 1105 Name of Law: null

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
1215-AB66	Final or interim final rulemaking	74 FR 41617	08/18/2009

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 45880	09/04/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Death Gratuity Beneficiary Designation	ca-40	Designation of a Recipient of a FECA Death Gratuity Payment under Section 1105 of Public Law 110-181 (Section 8102a)
Death Gratuity Official Notice of Employees' Death	ca-42	Official Notice of Employees' Death for Purposes of FECA Section 8102a Death Gratuity
Death Gratuity Claim for Survivor Benefits	ca-41	Claim for Survivor Benefits under FECA Section 8102a Death Gratuity

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ICR Summary of Burden

	Total Approved	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	2,635	0	2,635	0	0	0
Annual Time Burden (Hours)	659	0	659	0	0	0
Annual Cost Burden (Dollars)	12	0	12	0	0	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: This is a new collection request. There are minimal expense associated with the annual cost burden. The CA-40 is a beneficiary designation and maintained by the employing agency; in the event a claim is file for benefits by a designated beneficiary, a CA-41 is used and based on the anticipated number of respondents (25) x mailing and envelope costs (.47 cents), the annual cost burden is only $12.00. There is no cost to the public as the CA-42 is filed by the employing agency.

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Annual Cost to Federal Government: $35,624

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

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

Is this ICR related to the Pandemic Response? Uncollected

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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: 08/28/2009

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