Death Gratuity Claim for Survivor Benefits

Death Gratuity

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0017 can be found here:

Documents and Forms

Document Name Document Type
Form ca-41 Death Gratuity Claim for Survivor Benefits Form and Instruction
ca-41 Claim for Survivor Benefits under FECA Section 8102a Dea CA-41form 8-27-2009.doc www.dol.gov/esa/regs/compliance/owcp/forms.htm Form and Instruction

Information Collection (IC) Details

IC Title:	Death Gratuity Claim for Survivor Benefits	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-41	Claim for Survivor Benefits under FECA Section 8102a Death Gratuity	CA-41form 8-27-2009.doc	http://www.dol.gov/esa/regs/compliance/owcp/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: 25	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	25	25
Annual IC Time Burden (Hours)	6	6
Annual IC Cost Burden (Dollars)	12	12

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.