Information Collection

Death Gratuity Official Notice of Employees' Death

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

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-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 %

table that charts list of burden
	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

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.