Claim for Continuance of Compensation

ICR 201003-1240-015

OMB: 1240-0015

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supplementary Document
2008-02-21
Supplementary Document
2008-02-21
Supplementary Document
2008-02-21
Supplementary Document
2008-02-21
Supporting Statement A
2008-02-21
IC Document Collections
IC ID
Document
Title
Status
13838 Modified
ICR Details
1240-0015 201003-1240-015
Historical Active 200503-1215-002
DOL/OWCP
Claim for Continuance of Compensation
Extension without change of a currently approved collection   No
Regular
Approved without change 03/12/2010
Retrieve Notice of Action (NOA) 03/12/2010
  Inventory as of this Action Requested Previously Approved
05/31/2011 36 Months From Approved
4,850 0 5,450
403 0 454
1,988 0 2,000

This form is used to obtain information from eligible survivors receiving death benefits for an extended period of time. This information is necessary to ensure that compensation being paid is accurate.

US Code: 5 USC 8133 Name of Law: Federal Employees' Compensation Act
  
None

Not associated with rulemaking

  72 FR 69230 12/07/2007
73 FR 22432 04/25/2008
No

1
IC Title Form No. Form Name
Claim for Continuance of Compensation CA-12 Claim for Continuance of Compensation Under the Federal Employees' Compensation Act

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 4,850 5,450 0 0 -600 0
Annual Time Burden (Hours) 403 454 0 0 -51 0
Annual Cost Burden (Dollars) 1,988 2,000 0 0 -12 0
No
No
The number of persons receiving death benefits has decreased by 600 from 5450 to 4850, leading to a decrease in the burden hours from 454 to 403 - a decrease of 51 - and a decrease in cost burden of $12.

$13,704
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Carol Adams 904 357-4747 ext. 74105

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
04/25/2008


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