Death Gratuity Official Notice of Employees' Death

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⚠️ Notice: This information collection may be referencing outdated material.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-42 Death Gratuity Official Notice of Employees' Death Form and Instruction
ca-42 Official Notice of Employees' Death for Purposes of FECA CA-42-1240 revision.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction

Information Collection (IC) Details

IC Title:	Death Gratuity Official Notice of Employees' Death	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

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	ca-42	Official Notice of Employees' Death for Purposes of FECA Section 8102a Death Gratuity	CA-42-1240 revision.pdf	http://www.dol.gov/owcp/dfec/regs/compliance/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: 10	Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	0	0

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.