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Claim for Compensation by a Dependent Information Reports
Claim for Compensation by a Dependent Information Reports
OMB: 1240-0013
IC ID: 13841
OMB.report
DOL/OWCP
OMB 1240-0013
ICR 202302-1240-003
IC 13841
( )
Documents and Forms
Document Name
Document Type
1240-0013 Death Comp Due.docx
Other-
1240-0013 Death Comp Due.docx
Other-
StudentDependency.rtf
Other-
StudentDependency.rtf
Other-
CA-5 Claim for Compensation by Surviving Spouse and/or Childr
ca-5.pdf
www.dol.gov/sites/dolgov/files/owcp/regs/compliance/ca-5.pdf
Form and Instruction
CA-5 Claim for Compensation by Surviving Spouse and/or Childr
ca-5.pdf
www.dol.gov/sites/dolgov/files/owcp/regs/compliance/ca-5.pdf
Form and Instruction
CA-5b Claim for Compensation by Parents, Brothers, Sisters, Gr
ca-5b.pdf
www.dol.gov/sites/dolgov/files/owcp/regs/compliance/ca-5b.pdf
Form and Instruction
CA-5b Claim for Compensation by Parents, Brothers, Sisters, Gr
ca-5b.pdf
www.dol.gov/sites/dolgov/files/owcp/regs/compliance/ca-5b.pdf
Form and Instruction
CA-1031 Letter to Dependents to Verify Claimant Support
ca-1031.pdf
www.dol.gov/sites/dolgov/files/owcp/regs/compliance/ca-1031.pdf
Form
CA-1031 Letter to Dependents to Verify Claimant Support
ca-1031.pdf
www.dol.gov/sites/dolgov/files/owcp/regs/compliance/ca-1031.pdf
Form
CA-1074 Letter to Parents in Death Claim Development
1240-0013 Letter to Parents in Death Claim Development (CA-1074).pdf
www.dol.gov/sites/dolgov/files/owcp/regs/compliance/ca-1074.pdf
Form
CA-1074 Letter to Parents in Death Claim Development
1240-0013 Letter to Parents in Death Claim Development (CA-1074).pdf
www.dol.gov/sites/dolgov/files/owcp/regs/compliance/ca-1074.pdf
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Claim for Compensation by a Dependent Information Reports
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
20 CFR 10.417
20 CFR 10.105
20 CFR 10.535
20 CFR 10.537
20 CFR 10.7
20 CFR 10.410
20 CFR 10.413
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Other-
1240-0013 Death Comp Due.docx
Yes
Yes
Paper Only
Other-
StudentDependency.rtf
Yes
Yes
Paper Only
Form and Instruction
CA-5
Claim for Compensation by Surviving Spouse and/or Children
ca-5.pdf
https://www.dol.gov/sites/dolgov/files/owcp/regs/compliance/ca-5.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CA-5b
Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandchildren
ca-5b.pdf
https://www.dol.gov/sites/dolgov/files/owcp/regs/compliance/ca-5b.pdf
Yes
Yes
Fillable Fileable
Form
CA-1031
Letter to Dependents to Verify Claimant Support
ca-1031.pdf
https://www.dol.gov/sites/dolgov/files/owcp/regs/compliance/ca-1031.pdf
Yes
Yes
Printable Only
Form
CA-1074
Letter to Parents in Death Claim Development
1240-0013 Letter to Parents in Death Claim Development (CA-1074).pdf
https://www.dol.gov/sites/dolgov/files/owcp/regs/compliance/ca-1074.pdf
Yes
Yes
Printable Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Income Security
Subfunction:
Survivor Compensation
Privacy Act System of Records
Title:
DOL/GOVT-1
FR Citation:
81 FR 47418
Number of Respondents:
1,241
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
71 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
1,241
0
0
308
0
933
Annual IC Time Burden (Hours)
1,063
0
0
263
0
800
Annual IC Cost Burden (Dollars)
556
0
0
15
0
541
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.