Claim for Compensation by Dependents Information Reports

ICR 200403-1215-002

OMB: 1215-0155

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
1215-0155 200403-1215-002
Historical Active 200102-1215-005
DOL/ESA
Claim for Compensation by Dependents Information Reports
Extension without change of a currently approved collection   No
Regular
Approved without change 05/27/2004
Retrieve Notice of Action (NOA) 03/12/2004
  Inventory as of this Action Requested Previously Approved
05/31/2007 05/31/2007 05/31/2004
1,880 0 1,895
1,077 0 1,210
0 0 0

These reports request information from the survivors of deceased Federal employees which verify dependents status when making a claim for benefits and on a periodic basis in accepted claims. Some of the forms are used to obtain information on claimed dependents in disability cases.

None
None


No

1
IC Title Form No. Form Name
Claim for Compensation by Dependents Information Reports CA-5, CA-5B, CA-1031, CA-1074

  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 1,880 1,895 0 0 -15 0
Annual Time Burden (Hours) 1,077 1,210 0 0 -133 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
03/12/2004


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