CA-1074 Request for Clarification of CA-5b

U.S. Department of Labor

Employment Standards Administration
Office of Workers' Compensation Programs
Washington, D.C. 20210
File Number:

CA1074-O-COM
File Number:
Date of Death:
Employee:

Dear

:

Additional information is needed in support of your claim for dependency
compensation. Please supply answers to all questions on the attached questionnaire
and complete the affidavit which follows.
Further consideration will be given to your claim on receipt of this evidence.
This information is required to obtain a benefit (5 U.S.C. 8101 et seq.).
Sincerely,

NAME OF SIGNER
TITLE
Enclosure(s): EN1074
CA1074-O-COM

BPA

OMB Clearance #1215-0155,

Exp.

Date 05/31/2007

Working for America's Workforce

CA1074-1199

File Number:
Date of Death:

EVIDENCE REQUIRED IN SUPPORT OF A DEPENDENCY CLAIM

1. State the inclusive dates the deceased was employed during the 12 months
immediately preceding death. Give the names and addresses of his employers during
that period, the rate of pay, and the total amount earned in each job.

2. State whether the deceased was living away from home at any time during
the 12-month period before death. If so, give the inclusive dates. Forward any
canceled checks, money order receipts, letters, or other evidence of the fact that
the deceased contributed to your support during that time.

3. If you are now employed, give your Social Security account number, the
name of your employer, your wages, and your occupation. If not now employed,
explain why.

4. State whether your husband (or wife) survives. If he is employed, give
his Social Security account number, employer's name, amount of wages, and
occupation. If not employed, state why.

5. Furnish names and relationship to you of all persons who lived in the same
household with you during the year preceding the death, and the monthly amount
contributed by each toward support of the household.

EN1074-1196

Page 1

File Number:
Date of Death:

EVIDENCE REQUIRED IN SUPPORT OF A DEPENDENCY CLAIM

6. State what support you have received from your surviving children since
the death of the decedent. If they are now living with you and are not
contributing to your support, state why.

7. List all real or personal property owned by you and your husband (wife),
including money on deposit in the bank or invested, and the income from all
property and investments.

8.

Submit a copy of the record of birth of the deceased.

9. Submit an affidavit from at least two persons (preferably not related to
you or to the decedent) who have actual knowledge of whether the decedent
contributed to your support during the 12 months before death; whether you were
dependent on these contributions for your livelihood; why this was true and how
they (the affiants) know it to be true.

EN1074-1196

Page 2

File Number:
Date of Death:

I certify that the information given in response to this questionnaire is true to the
best of my knowledge and belief. I further understand that any person who knowingly
makes any false statement, misrepresentation, concealment of fact, or any other act of
fraud to obtain compensation as provided by the FECA or who knowingly accepts
compensation to which that person is not entitled is subject to felony criminal
prosecution and may, under appropriate criminal provisions, be punished by a fine or
imprisonment, or both.

Signature

Date

EN1074-1196

Page 3

File Number:
Date of Death:

NOTICE TO RECIPIENT

Public reporting burden for this collection of information estimated to be 60
minutes per response, including time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Send comments regarding the burden
estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to the US Department of Labor, OWCP, Room
S3229, 200 Constitution Avenue, NW, Washington, DC 20210. DO NOT SEND THE
COMPLETED FORM TO THIS ADDRESS. Persons are not required to respond to this
request unless it displays a currently valid OMB control number.

EN1074-0598

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