Information Collection

Claim for Continuance of Compensation

IC 13838 under ICR 201011-1240-003 · OMB 1240-0015.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0015 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CA-12 Claim for Continuance of Compensation	Form
CA-12 Claim for Continuance of Compensation Under the Federal CA-12 (2) revised final.pdf www.dol.gov/owcp/regs/compliance/ca-12.pdf	Form

IC Title:

Claim for Continuance of Compensation

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 10.126

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CA-12	Claim for Continuance of Compensation Under the Federal Employees' Compensation Act	CA-12 (2) revised final.pdf	http://www.dol.gov/owcp/regs/compliance/ca-12.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records

Title: DOL/GOVT-1

FR Citation: 67 FR 16817

Number of Respondents: 4,570

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,570	-280	4,850
Annual IC Time Burden (Hours)	379	-24	403
Annual IC Cost Burden (Dollars)	2,011	23	1,988

Documents for IC

table that charts IC Documents
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.