Form ca-40 Designation of a Recipient of a FECA Death Gratuity Paym

OMB Number: 1215-XXXX

Expiration Date: Month XX, XXXX

CA 40 Designation of a Recipient of the Federal Employees' Compensation Act Death Gratuity Payment under

Section 1105 of Public Law 110-181 (Section 8102a)

A. Identifying Information about the Federal Employee

Name (Last, First, Middle)	Date of Birth	Social Security Number
Department or Agency in which presently employed (include Bureau, Division, and phone number)		Location (City, State, and ZIP code)

B. Designating an Alternate Order of Precedence

If you have no surviving spouse or child eligible to receive the death gratuity, and you wish to designate any one or more of your parents or brothers or sisters to receive specific shares (%)of the gratuity, please fill in the required boxes below. If you designate more than one individual and do not indicate a share for each individual, the death gratuity will be paid to those individuals in equal shares. An individual designated below must be living at the time of payment to receive any or all of your death gratuity.

First Name, middle initial, and last name of each designee	Address (including ZIP code) of each designee	Relationship to you (must be parent, brother, or sister)	Share to be provided to each designee

I

C. Additional Alternate Beneficiary Designation Provision

n addition to or instead of the above, you may designate any person or persons to receive up to 50% of your death gratuity. If you do not designate anyone in this section, 100% of the death gratuity will be disbursed according to the order of precedence described in the instructions. Under this provision, you may designate a maximum of 50% of the death gratuity in 10% increments. If you utilize this designation provision, the undesignated portion of the death gratuity will be disbursed as specified in the order of precedence. An individual designated below must be living at the time of payment to receive any or all of your death gratuity.

First Name, middle initial, and last name of each designee	Address (including Zip Code) of each designee	Share to be provided to each designee (must be in 10% increments)

CA-40 Designation of a Recipient of the Death Gratuity Payment under

Section 1105 of Public Law 110-181

D. Statement of Federal Employee Completing this Form

I understand that this Designation is not valid unless delivered to an official of the employing establishment prior to the death of the employee and that it will stay in effect unless it is cancelled.

I understand that if this Designation is invalid for any reason, the death gratuity will be paid according to the next most recent valid designation. In the event no designation has been made, the death gratuity will be paid according to the order of precedence in section 1105 of Public Law 110-181 as described in the instructions.

I am canceling any and all previous Designations of the death gratuity payment under Public Law 110-181, section 1105, and am now designating the recipients named above. NOTE: If this notice is completed by the employee, it must be sent to, signed on by the employee’s supervisor and retained by the employing agency.

Signature of the Federal Employee. This form is not valid unless the employee signs in this box and enters a date in the box to the right.

Date (mm/dd/yyyy)

E. Signature of the Employing Establishment Official Receiving this Form

I have received this form from the federal employee who has signed above. To the best of my knowledge and belief, the employee has filled out this form completely in accordance with the instructions on the form.

Signature of the Employing Establishment Official. This form is not valid unless, prior to the death of the employee, the official signs in this box and enters a date in the box to the right.	Date (mm/dd/yyyy)
Printed Name, Title, Address and phone and fax numbers of the Employing Establishment Official. NAME: TITLE: ADDRESS: PHONE NUMBER: FAX NUMBER:

PRIVACY ACT STATEMENT

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees’ Compensation Act (FECA), as amended and extended (5 U.S.C. 8101, et seq.) including the Death Gratuity in section 1105 of Public Law 110-181 is administered by the Office of Workers' Compensation Programs of the U.S. Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2) Information which the Office has will be used to determine eligibility for and the amount of benefits payable under the FECA, and may be verified through computer matches or other appropriate means. (3) Information may be given to the Federal agency which employed the claimant at the time of injury in order to verify statements made, answer questions concerning the status of the claim, verify billing, and to consider issues relating to entitlement to benefits or other relevant matters. (4) Information may be given to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA, to determine whether benefits are being paid properly, including whether prohibited dual payments are being made, and, where appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection Act. (5) Disclosure of the claimant's social security number (SSN) or tax identifying number (TIN) on this form is mandatory (Executive Order 9397, dated November 22, 1943). The SSN (and/or TIN), and other information maintained by the Office, may be used for identification, to support debt collection efforts carried on by the Federal government, and for other purposes required or authorized by law. (6) Failure to disclose all requested information may delay the processing of the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB number. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is voluntary (5. U.S.C. 8102a). Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Workers’ Compensation Programs, U.S. Department of Labor, Room S3524, 200 Constitution Avenue, N.W., Washington, D.C. 20210, and reference the OMB Control Number 1215-XXXX. Note: Do not submit the completed claim form to this address.

CA-40 Instructions Designation of a Recipient of the Death Gratuity Payment under

Section 1105 of Public Law 110-181

INSTRUCTIONS

The Death Gratuity Payment

If a federal civilian employee or an employee of a nonappropriated fund instrumentality dies of injuries incurred in connection with his or her service with an Armed Force in a contingency operation, his or her eligible survivors may receive a death gratuity payment of up to $100,000. The gratuity is a one-time payment disbursed to the highest ranked survivor or survivors of the employee according to the order of precedence below.

You do not need to fill out this form if you are satisfied that 100% of the gratuity will be paid entirely to the survivor highest on the list below:

1. Your surviving spouse.

2. If you do not have a surviving spouse, your death gratuity will be paid to your children, in equal shares. Your children include any adopted children, stepchildren who are part of your household at the time of death, and any illegitimate children, subject to the following limitation. An illegitimate child of a male decedent only qualifies as an eligible survivor if the child:

   • has been acknowledged in writing signed by the decedent;

   • has been judicially determined, before the decedent's death, to be his child;

   • has been otherwise proved, by evidence satisfactory to the employing agency, to be a child of the decedent; or

   • is a child to whose support the decedent had been judicially ordered to contribute.

3. If you have no surviving spouse or eligible child, you can choose to divide your death gratuity among your parents or brothers or sisters, as you designate in section B of the form.

   • The term “parents” includes adoptive parents and persons who stood in loco parentis to the decedent for not less than one year before the decedent became an employee covered by this provision, but the term is limited to one father or mother or their counterparts.

   • “Brothers” and “sisters” include half-brothers and half-sisters, and brothers and sisters through adoption.

4. If you have no surviving spouse or eligible child and do not designate anyone in section B of the form, your death gratuity will be paid to your living parent or parents, in equal shares.

5. If you have no surviving spouse, eligible child, or living parent and do not designate anyone in section B of the form, your death gratuity will be paid to your brothers and sisters, in equal shares.

6. If you wish, you may use Section C to designate up to half of this benefit to an alternate beneficiary(ies). In order for such a designation to be valid, the form must be otherwise valid and you must designate a percentage in 10% increments, the alternate must be alive, and the alternate beneficiary must be a person.

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CA-40

September 2009