Information Collection

Death Gratuity Beneficiary Designation

IC 190277 under ICR 200908-1215-001 · OMB 1215-0206.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form ca-40 Death Gratuity Beneficiary Designation	Form and Instruction
ca-40 Designation of a Recipient of a FECA Death Gratuity Paym CA 40 Death Gratuity Beneficiary Designation -8-25-2009 SDL[1].doc www.dol.gov/esa/regs/compliance/owcp/forms.htm	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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 and Instruction	ca-40	Designation of a Recipient of a FECA Death Gratuity Payment under Section 1105 of Public Law 110-181 (Section 8102a)	CA 40 Death Gratuity Beneficiary Designation -8-25-2009 SDL[1].doc	http://www.dol.gov/esa/regs/compliance/owcp/forms.htm	Yes	No	Fillable Printable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title: DOL/Govt -1

FR Citation: 67 FR 16826

Number of Respondents: 2,600

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	Program Change Due to New Statute
Annual Number of Responses for this IC	2,600	2,600
Annual IC Time Burden (Hours)	650	650
Annual IC Cost Burden (Dollars)	0	0

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.