Death Gratuity

Forms and Documents

Document Name	Status
Form ca-42 Death Gratuity Official Notice of Employees' Death Form and Instruction	Unchanged
Form ca-41 Death Gratuity Claim for Survivor Benefits Form and Instruction	Unchanged
Form ca-40 Death Gratuity Beneficiary Designation Form and Instruction	Modified
Death Gratuity Information-DFEC website (2).doc Supplementary Document	2012-04-24
NOTICE TO REVIEWER SUMMARY OF REVISIONS.doc Justification for No Material/Nonsubstantive Change	2012-04-24
revisions 1240-0017.doc Supplementary Document	2010-05-13
dol-govt-1.doc Supplementary Document	2009-08-10
2009 opm salary table (4).pdf Supplementary Document	2009-08-10
2009 databases tables and calculators by subject 8-10-09.pdf Supplementary Document	2009-08-10
Death Gratuity Forms Supporting Statement 1-14-10_revised.doc Supporting Statement A	2010-05-13

IC Document Collections

IC ID	Document Title	Status
190297	Death Gratuity Official Notice of Employees' Death Form and Instruction	Unchanged
190296	Death Gratuity Claim for Survivor Benefits Form and Instruction	Unchanged
190277	Death Gratuity Beneficiary Designation Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0017	ICR Reference No: 201204-1240-001
Status: Historical Active	Previous ICR Reference No: 201004-1240-012
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Death Gratuity
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/02/2012
	Date Received in OIRA: 04/25/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2013	06/30/2013	06/30/2013
Responses	2,635	0	2,635
Time Burden (Hours)	659	0	659
Cost Burden (Dollars)	12	0	12

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Abstract: The National Defense Authorization Act for Fiscal Year 2008, Public Law 110-181, was enacted on January 28, 2008. Section 1105 of P.L. 110-181 amended the Federal Employees' Compensation Act (FECA) creating a new section 8102a effective upon enactment. This section establishes a new FECA death gratuity benefit of up to $100,000 for eligible beneficiaries of federal employees and Non-Appropriated Fund Instrumentality (NAFI) employees who die from injuries incurred in connection with service with an Armed Force in a contingency operation. Section 8102a also permits agencies to authorize retroactive payment of the death gratuity for employees who died on or after October 7, 2001, in service with an Armed Force in the theater of operations of Operation Enduring Freedom and Operation Iraqi Freedom. Form CA-40 requests the information necessary from the employee to accomplish this variance. Form CA-41 provides the means for those named beneficiaries and possible recipients to file claims for those benefits and requests information from such claimants so that OWCP may determine their eligibility for payment. Further, the statute and regulations require agencies to notify OWCP immediately upon the death of a covered employee. CA-42 provides the means to accomplish this notification and requests information necessary to administer any claim for benefits resulting from such a death.

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Authorizing Statute(s): US Code: 5 USC 8102a Name of Law: Amendment to the FECA, Death Gratuity
   PL: Pub.L. 110 - 181 1105 Name of Law: National Defense Authorization Act
   PL: Pub.L. 112 - 81 1121 Name of Law: National Defense Authorization Act for Fiscal Year 2012
  

Citations for New Statutory Requirements: PL: Pub.L. 110 - 181 1105 Name of Law: NATIONAL DEFENSE AUTHORIZATION ACT FOR FISCAL YEAR 2008
PL: Pub.L. 112 - 81 1121 Name of Law: NATIONAL DEFENSE AUTHORIZATION ACT FOR FISCAL YEAR 2012

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 4586	01/28/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 60062	05/28/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Death Gratuity Beneficiary Designation	ca-40	CA-40 Designation of a Recipient of the Federal Employees' Compensation Act Death Gratuity Payment under 5 U.S.C. § 8102a
Death Gratuity Official Notice of Employees' Death	ca-42	Official Notice of Employees' Death for Purposes of FECA Section 8102a Death Gratuity
Death Gratuity Claim for Survivor Benefits	ca-41	Claim for Survivor Benefits under FECA Section 8102a Death Gratuity

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	2,635	2,635	0	0	0	0
Annual Time Burden (Hours)	659	659	0	0	0	0
Annual Cost Burden (Dollars)	12	12	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $35,624

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/25/2012

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