Form CA-1031 Claimant Support of Dependent

U.S. DEPARTMENT OF LABOR

Office of Workers’ Compensation Programs
Washington, D.C. 20210

OMB No: 1240-0013
Expiration Date: xx-xx-xxxx

File Number:

Sender (Address):

Date:

Phone:
Date of Injury:
Employee:
Dep(s):

To (Recipient’s Address)
Dear (Recipient’s Name):
To help us reach a decision regarding a claim for compensation filed
by__________________, please furnish the information requested below. This
information is required to obtain or retain a benefit (5 U.S.C. 8101 et seq.).
1. State your relationship to employee (that is, spouse, natural parent or guardian of
dependent(s) named above, or parent of employee).
______________________________________________________________________
2. State the amount of money that employee regularly contributes to your support or to
the support of the dependent(s) named above. State how often the contributions are
made – weekly, monthly, etc. If contributions are not made at regular intervals or in the
form of money, please explain.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
If you have a disability and are in need of communication assistance (such as
alternate formats or sign language interpretation), accommodation(s) and/or
modification(s), please contact OWCP.

CA-1031
Revised (05-16)

3. Approximate date such contributions were first made:
______________________________________________________________________
4. If you are natural parent or legal guardian of the dependent(s) named above, give the
age and relationships to the employee of each dependent.
______________________________________________________________________
______________________________________________________________________
5. If you are a parent of the employee, state the source and amount of all your other
income. If none, so state.
______________________________________________________________________
______________________________________________________________________

I certify that the information provided above is true and accurate to the best of my
knowledge and belief. 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 civil or administrative remedies as well as criminal prosecution
and may, under appropriate criminal provisions, be punished by a fine or imprisonment,
or both. In addition, a state or federal criminal conviction for FECA fraud will result in
termination of all current and future FECA benefits

__________________________________________
Signature

____________
Date

Sincerely,

Name of Signer:
Title
cc: (Names/Addressees receiving copy)

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Revised (05-16)
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Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond
to a collection of information unless such collection displays a valid OMB control
number. Public reporting burden for this collection of information is estimated to average
20 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. The authority for requesting this information is 5 U.S.C.
8101 et seq. The information will be used to determine entitlement to benefits.
Furnishing the requested information is required for the claimant to obtain or retain a
benefit. Send comments regarding the burden estimate or any aspect of this collection
of information, including suggestions for reducing this burden, to the Office of Workers'
Compensation Programs, Department of Labor, Room S-3229, 200 Constitution Avenue,
NW, Washington, DC 20210, and reference the OMB Control Number 1240-0013.
Note: please do not send the completed form to this office; rather, send it to the address
shown on the letterhead.

CA-1031
Revised (05-16)
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