Information Collection

Death Gratuity Official Notice of Employees' Death

IC 190297 under ICR 200908-1215-001 · OMB 1215-0206.

Documents and Forms

Document Name Document Type
Form ca-42 Death Gratuity Official Notice of Employees' Death Form and Instruction
ca-42 Official Notice of Employees' Death for Purposes of FECA CA-42 08-27-2009.doc www.dol.gov/esa/owcp/dfec/regs/compliance/forms.htm Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Death Gratuity Official Notice of Employees' Death	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	ca-42	Official Notice of Employees' Death for Purposes of FECA Section 8102a Death Gratuity	CA-42 08-27-2009.doc	http://www.dol.gov/esa/owcp/dfec/regs/compliance/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: 10	Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.