Claim for Compensation by a Dependent Information Reports

Claim for Compensation by a Dependent Information Reports

OMB: 1240-0013

IC ID: 13841

Information Collection (IC) Details

View Information Collection (IC)

Claim for Compensation by a Dependent Information Reports
 
No Modified
 
Required to Obtain or Retain Benefits
 
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

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

Income Security Survivor Compensation

DOL/GOVT-1  81 FR 47418

1,241 0
   
Individuals or Households
 
   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

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.

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