CA-1031 Claimant Support of Dependent

U.S. Department of Labor

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

CA1031-O-D
File Number:
Date of Injury:
Employee:
Dep(s):

Dear

:

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).
1. State your relationship to employee (that is, wife, husband, natural
parent or guardian of dependent(s) named above, or parent of employee).
_________________________________________________________________________
2. State the amount of money the 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.
_________________________________________________________________________
_________________________________________________________________________
3.

Approximate date such contributions were first made: ________________

4. If you are a natural parent or legal guardian of the dependent(s)
named above, give the age and relationship 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. _____________________________
_________________________________________________________________________

BPA

OMB Clearance # 1215-0155, Exp. Date 05/31/2007

Working for America's Workforce

CA1031-0598

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File Number:
Employee:

I certify that each and every statement made above is true to the best of my
knowledge. 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

Sincerely,

NAME OF SIGNER
TITLE

NOTICE TO RECIPIENT

Public reporting burden for this collection of information estimated to
vary from 10 to 20 minutes per response with an average of 15 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 collection of information unless it displays a currently valid OMB
control number.

CA1031-1199

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