Notice to Reviewer

NOTICE TO REVIEWER

Request Type:  Non-substantive Change

Employing Agency:  Office of Workers’ Compensation Programs/Division of Federal Employees’ Compensation

Form Number/Name:  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). 

OMB/Expiration Date:  1240-0017, June 30, 2013.

Basis for Change:

Public Law 112-81, of the National Defense Authorization Act, was signed by the President on 12-31-2011.  The Law provides that a designation can be more than 50 % to someone not in the order of precedence.  Additionally, if someone other than a spouse is designated, the spouse would need to be notified.  The present form does not reflect these changes, and therefore, requires minor revisions to comply with PL 112-81.    

The Division of Federal Employees Compensation is not seeking any changes in the information that is being collected.  The form is only being revised to instruct respondents of an obligation that the employing agency has to inform a spouse when certain actions are taken and in making certain other minor clarifications. 

SUMMARY OF REVISIONS

CA-40 (OMB 1240-0017, Expiration Date June 30, 2013)

PAGE 1

Present Form Title

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).

Replace with:

CA-40, Designation of a Recipient of the Federal Employees' Compensation Act Death Gratuity Payment under 5 U.S.C. § 8102a).

Add following statement to bottom of form:

Note: Effective December 31, 2011, employing agencies are required to notify your spouse if you have designated all or a portion of the death gratuity to someone other than your spouse. Section 1121 of Public Law 112-81.

PAGE 2

Section C, Additional Beneficiary Designation Provision

Present Form.

In addition to or instead of the above, you may designate any person or persons to receive up to 50% of your death gratuity. If you do not designate anyone in this section, 100% of the death gratuity will be disbursed according to the order of precedence provided by statute and described in the instructions. Under this provision, you may designate a maximum of 50% of the death gratuity in 10% increments. If you utilize this designation provision, the undesignated portion of the death gratuity will be disbursed as specified in the order of precedence. An individual designated below must be living at the time of payment to receive any or all of your death gratuity.

Replace with:

In addition to or instead of the above, you may designate another person or persons to receive all or a portion of your death gratuity. If you do not designate anyone in this section, 100% of the death gratuity will be disbursed according to the order of precedence provided by statute and described in the instructions. Under this provision, you may designate up to 100% of the death gratuity in 10% increments. If you utilize this designation provision, the undesignated portion of the death gratuity will be disbursed as specified in the order of precedence. An individual designated below must be living at the time of payment to receive any or all of your death gratuity.

Section D, Statement of Federal Employee Completing this Form

2d paragraph.

Present Form:

I understand that if this Designation is invalid for any reason, the death gratuity will be paid according to the next most recent valid designation. In the event no designation has been made, the death gratuity will be paid according to the order of precedence in section 1105 of Public Law 110-181 as described in the instructions.

Replace with:

I understand that if this Designation is invalid for any reason, the death gratuity will be paid according to the next most recent valid designation. In the event no valid designation has been made, the death gratuity will be paid according to the order of precedence in as described in the instructions (5 U.S.C. § 8102a).

3^rd paragraph (first/second sentences):

Present Form:

I am canceling any and all previous Designations of the death gratuity payment under Public Law 110-181, section 1105, and……

Replace with:

I am canceling any and all previous Designations of the death gratuity payment under 5 U.S.C. § 8102a and ….

PAGE 3

Present Form-Privacy Act Statement

(opening sentence reads as follows):

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees’ Compensation Act (FECA), as amended and extended (5 U.S.C. 8101, et seq.) including the Death Gratuity in section 1105 of Public Law 110-181 is administered by the Office of Workers’ Compensation Programs of the U.S. Department of Labor, which ………level of benefits.

Replace with:

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees’ Compensation Act (FECA), as amended and extended (5 U.S.C. 8101, et seq.) including the amendment to the Federal Employees' Compensation Act, 5 U.S.C. § 8102a – Death Gratuity is administered by the Office of Workers' Compensation Programs of the U.S. Department of Labor, which …….level of benefits.

PAGE 4 (Instructions)

Add the following statement after the first paragraph under The Death Gratuity Payment.

NOTE: Effective December 31, 2011, employing agencies are required to notify your spouse, if one exists, if you designate all or a portion of the death gratuity to someone other than your spouse. 

NOTE TO EMPLOYING AGENCIES:  If the federal employee completing this form has a spouse,  the agency is required effective December 31, 2011  to notify that spouse if the federal employee designates anyone other than that spouse to receive all or a portion of the FECA death gratuity pursuant to 5 U.S.C. § 8102a.

Item 6 (first/second sentences)

Present Form

If you wish, you may use Section C to designate up to half of this benefit to an alternate beneficiary (ies).

Replace with:

If you wish, you may use Section C to designate all or a portion of this benefit to an alternate beneficiary(ies).

4