Form ca-41 Claim for Survivor Benefits under FECA Section 8102a Dea

OMB Number: 1215-XXXX

Expiration Date: Month XX, XXXX

Claim for Survivor Benefits Under the Federal Employees’ Compensation Act Section 8102a Death Gratuity (CA-41)

Deceased Employee Information

1. Name (Last, First, Middle) 2. Sex 3. Social Security Number

□ Male □ Female XXX-XX-XXXX

4. Date of Birth (DOB) 5. Date of Death (DOD) 6. Employer on date of death

XX/XX/XXXX XX/XX/XXXX XX/XX/XXXX

Survivor Information

7. Name (Last, First, Middle) 8. Sex 9. Social Security Number

□ Male □ Female XXX-XX-XXXX

10. DOB 11. Relationship to decedent (check boxes)

□ Spouse □ Child □ Step-Child

□ Parent □ Sibling □ Other: Please describe____________

12. Address 13. Telephone Numbers

15. Address 16. Phone

Injury/Occupational Illness Information

14. FECA Claim # 15. Date of Injury 16. Position held on date of injury

17. Employer at time of injury 18. Armed Force conducting the contingency operation in the region

□ Army □ Navy □ Air Force

□ Marine Corps □ Coast Guard

19. Place where injury/exposure occurred

20. Description of injury/exposure which led to the employee’s death

Survivor Declaration

I hereby certify that each and every statement made above is true and accurate to the best of my knowledge. Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud to obtain compensation as provided by 5 U.S. C. 8102a or who knowingly accepts compensation to which that person is not entitled is subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both.

Claimant signature ______________________ Date____________________

Privacy Act Statement

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees’ Compensation Act (FECA), as amended and extended (5 U.S.C. 8101, et seq.) including the Death Gratuity in section 1105 of Public Law 110-181 is administered by the Office of Workers' Compensation Programs of the U.S. Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2) Information which the Office has will be used to determine eligibility for and the amount of benefits payable under the FECA, and may be verified through computer matches or other appropriate means. (3) Information may be given to the Federal agency which employed the claimant at the time of injury in order to verify statements made, answer questions concerning the status of the claim, verify billing, and to consider issues relating to entitlement to benefits or other relevant matters. (4) Information may be given to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA, to determine whether benefits are being paid properly, including whether prohibited dual payments are being made, and, where appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection Act. (5) Disclosure of the claimant's social security number (SSN) or tax identifying number (TIN) on this form is mandatory (Executive Order 9397, dated November 22, 1943). The SSN (and/or TIN), and other information maintained by the Office, may be used for identification, to support debt collection efforts carried on by the Federal government, and for other purposes required or authorized by law. (6) Failure to disclose all requested information may delay the processing of the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain benefit (5. U.S.C. 8102a). Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Workers’ Compensation Programs, U.S. Department of Labor, Room S3524, 200 Constitution Avenue, N.W., Washington, D.C. 20210, and reference the OMB Control Number 1215-XXXX. Note: Please do not submit the completed claim form to this address. Completed claims are to be submitted to the appropriate district office of the Office of Workers’ Compensation Programs.

CA-41 Instructions

Complete all items on the form. If additional space is required to explain or clarify, attach a supplemental statement to the form. If the requested information is not submitted, the responsible party should explain the reason(s) for the delay and indicate when the information will be forthcoming. Submit the completed form and all other pertinent documentation to the Cleveland district office of the Department of Federal Employees’ Compensation.

Item #11 - Survivors are defined as follows:

• A spouse is the person legally married to the deceased employee at the time of death.

• A child refers to the employee’s natural children, adopted children, and some stepchildren. A stepchild must have been a part of the employee’s household (i.e. a part of the household per a written custody agreement or actually sharing a home for the majority of the time) at the time of death. For a natural child who is an illegitimate child of a male employee, the child must satisfy one of the criteria listed in 5 U.S.C. 8102a.

• Surviving parents include fathers and mothers through adoption and persons who stood in loco parentis to the employee for a period of not less than one year at any time before the person became an employee. A person will be considered in loco parentis when the person takes the employee into his or her home and treats them as member of his or her family, providing parental supervision, support, and education as if the employee were his or her own child. Only one father and one mother or their counterparts in loco parentis may be recognized. Preference is given to those who exercise a parental relationship on the date, or most nearly before ,the date on which the decedent became an employee.

Item #14 – If the claimant filed a claim for injury prior to the date of death, provide the claim number assigned to that claim.

Item #15 – If a claim was filed (see #14), then this is the date that will be utilized. If the employee did not file a claim for compensation for the injury which led to the employee’s death, the date of injury will need to be determined. If the traumatic injury was a definite occurrence which can be assigned to a time and place during one work day or shift, then this date will be used as the date of injury. If the employee’s death resulted from an occupational illness which developed over more than one day or work shift, then the date of injury will be the date that the employee became aware (or reasonably should have been aware) of the relationship between the illness and factors of employment.

Item #16 – For purposes of this benefit, the term “employee” has the meaning as stated in 5 U.S.C. 8101 and also includes Non-Appropriated Fund Instrumentality (NAFI) employees as defined in section 1587(a)(1) of Title 10 of the United States Code.

Item #18 – For the purposes of this benefit, the term “armed forces” is limited to the options provided herein. The term “contingency operation” includes a basic contingency operation, humanitarian operations, peacekeeping operations, and similar operations. The definitions of these types of operations can be found in title 10 of the United States Code.

Item #21 – List other payments made for a death gratuity only (not those made for death under section 8133 of the FECA, retirement, life insurance, or any other federal benefit). Death gratuities that could be paid include but are not limited to: payment under section 413 of the Foreign Service Act of 1980; the gratuity provision of the Emergency Supplemental Appropriations Act for Defense, the Global War on Terror, and Hurricane Recovery, 2006; the $10,000 death gratuity to the personal representative of civilian employees, at Title VI, Section 651 of the Omnibus Consolidated Appropriations Act of 1996 (Public Law 104-208, September 30, 1996); the death gratuity for members of the armed forces or any employee of the Department of Defense dying outside the United States while assigned to intelligence duties, at 10 U.S.C. § 1489; and the death gratuity for employees of the Central Intelligence Agency, at 50 U.S.C. § 403k.

Item #23 – For a definition of eligible survivors, see the instructions above for item 11. If you answered ‘yes’ to item 22, please list any beneficiaries designated by the deceased employee here along with current contact information.

Any person signing this form avers that person is either a survivor or beneficiary of a covered employee or is entitled, by law, to sign a claim on behalf of the named survivor or beneficiary.

` CA-41

Page 4

September 2009