Information Collection

Claim for Compensation by Dependents Information Reports

IC 13841 under ICR 201003-1240-013 · OMB 1240-0013.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0013 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CA-5 Claim for Compensation by Dependents Information Reports	Form and Instruction
CompensationDueAtDeath.rtf	Other-Letter
StudentDependency.rtf	Other-Letter
CA-5 Claim for Compensaion by Widow, Widower, and/or Children ca-5.pdf www.dol.gov/esa/regs/compliance/owcp/forms.htm	Form and Instruction
CA-1031 Claimant Support of Dependent ca-1031.pdf www.dol.gov/esa/regs/compliance/owcp/forms.htm	Form
CA-5B Claim for Compensation by Parents, Brothers, Sisters, Gr ca-5b.pdf www.dol.gov/esa/regs/compliance/owcp/forms.htm	Form and Instruction
CA-1074 Request for Clarification of CA-5b ca-1074.pdf www.dol.gov/esa/regs/compliance/owxp/forms.htm	Form

IC Title:

Claim for Compensation by Dependents Information Reports

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 10.7 20 CFR 10.105 20 CFR 10.410 20 CFR 10.413 20 CFR 10.417 20 CFR 10.535 20 CFR 10.537

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-5	Claim for Compensaion by Widow, Widower, and/or Children	ca-5.pdf	http://www.dol.gov/esa/regs/compliance/owcp/forms.htm	Yes	No	Fillable Printable
Form	CA-1031	Claimant Support of Dependent	ca-1031.pdf	http://www.dol.gov/esa/regs/compliance/owcp/forms.htm	Yes	No	Printable Only
Form and Instruction	CA-5B	Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandshildren	ca-5b.pdf	http://www.dol.gov/esa/regs/compliance/owcp/forms.htm	Yes	No	Fillable Printable
Form	CA-1074	Request for Clarification of CA-5b	ca-1074.pdf	http://www.dol.gov/esa/regs/compliance/owxp/forms.htm	Yes	No	Printable Only
Other-Letter			CompensationDueAtDeath.rtf		No		Paper Only
Other-Letter			StudentDependency.rtf		No		Paper Only

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,880

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	1,880	0	1,880
Annual IC Time Burden (Hours)	1,077	0	1,077
Annual IC Cost Burden (Dollars)	452	452	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.