Information Collection

Claim for Continuance of Compensation

IC 13838 under ICR 200802-1215-003 · OMB 1215-0154.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CA-12 Claim for Continuance of Compensation Under the Federal Employees' Compensation Act Claim for Continuance of Compensation	Form
CA-12 Claim for Continuance of Compensation Under the Federal ca-12.pdf www.dol.gov/esa/regs/compliance/owcp/ca-12.pdf	Form

IC Title:

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 10.126

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CA-12			http://www.dol.gov/esa/regs/compliance/owcp/ca-12.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records

Title: DOL/GOVT-1

FR Citation: 67 FR 16817

Number of Respondents: 4,850

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,850	-600	5,450
Annual IC Time Burden (Hours)	403	-51	454
Annual IC Cost Burden (Dollars)	1,988	-12	2,000

Documents for IC

table that charts IC Documents
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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