Form ca-40 Designation of a Recipient of a FECA Death Gratuity Paym

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U.S. DEPARTMENT OF LABOR

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CA-40 Designation of a Recipient of the Federal Employees' Compensation Act
Death Gratuity Payment under
Section 1105 of Public Law 110-181 (Section 8102a)
A. Identifying Information about the Federal Employee


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B. Designating an Alternate Order of Precedence



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individual designated below must be living at the time of payment to receive any or all of your
death gratuity



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CA-40
Page 1
Revised January 2010

C. Additional Alternate Beneficiary Designation Provision
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SUHFHGHQFHAn individual designated below must be living at the time of payment to receive any
or all of your death gratuity.

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D. Statement of Federal Employee Completing this Form
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VHFWLRQDQGDPQRZGHVLJQDWLQJWKHUHFLSLHQWVQDPHGDERYHNOTE:  If this notice is

completed by the employee, it must be sent to, signed on by the employee’s supervisor and
retained by the employing agency.





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CA-40
Page 2
Revised January 2010

E. Signature of the Employing Establishment Official Receiving this Form

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the death of the employee, the official signs in this box and enters a date in the box
to the right.




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Previous edition usable

CA-40
Page 3
Revised January 2010

CA-40 Instructions Designation of a Recipient of the Death Gratuity
Payment under Section 1105 of Public Law 110-181


INSTRUCTIONS
The Death Gratuity Payment


If a federal civilian employee or an employee of a nonappropriated fund instrumentality dies of
injuries incurred in connection with his or her service with an Armed Force in a contingency
operation, his or her eligible survivors may receive a death gratuity payment of up to $100,000.
The gratuity is a one-time payment disbursed to the highest ranked survivor or survivors of the
employee according to the order of precedence below.
You do not need to fill out this form if you are satisfied that 100% of the gratuity will be
paid entirely to the survivor highest on the list below:
1. Your surviving spouse.
2. If you do not have a surviving spouse, your death gratuity will be paid to your children,
in equal shares. Your children include any adopted children, stepchildren who are part of
your household at the time of death, and any illegitimate children, subject to the
following limitation. An illegitimate child of a male decedent only qualifies as an
eligible survivor if the child:
x has been acknowledged in writing signed by the decedent;
x has been judicially determined, before the decedent's death, to be his child;
x has been otherwise proved, by evidence satisfactory to the employing agency, to
be a child of the decedent; or
x is a child to whose support the decedent had been judicially ordered to contribute.
3. If you have no surviving spouse or eligible child, you can choose to divide your death
gratuity among your parents or brothers or sisters, as you designate in section B of the
form.
x The term “parents” includes adoptive parents and persons who stood in loco
parentis to the decedent for not less than one year before the decedent became an
employee covered by this provision, but the term is limited to one father or
mother or their counterparts.
x “Brothers” and “sisters” include half-brothers and half-sisters, and brothers and
sisters through adoption.
4. If you have no surviving spouse or eligible child and do not designate anyone in section
B of the form, your death gratuity will be paid to your living parent or parents, in equal
shares.
 If you have no surviving spouse, eligible child, or living parent and do not designate
anyone in section B of the form, your death gratuity will be paid to your brothers and
sisters, in equal shares. 
 If you wish, you may use Section C to designate up to half of this benefit to an alternate
beneficiary(ies). In order for such a designation to be valid, the form must be otherwise
valid and you must designate a percentage in 10% increments, the alternate must be alive,
and the alternate beneficiary must be a person. 

Previous edition usable

CA-40
Page 4
Revised January 2010