Information Collection

Death Gratuity Beneficiary Designation

IC 190277 under ICR 201204-1240-001 · OMB 1240-0017.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0017 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form ca-40 Death Gratuity Beneficiary Designation	Form and Instruction
ca-40 CA-40 Designation of a Recipient of the Federal Employee CA 40 mjs (2) jv 3-12-12 feewc edits.docx www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction

IC Title:

Death Gratuity Beneficiary Designation

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 10

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 and Instruction	ca-40	CA-40 Designation of a Recipient of the Federal Employees' Compensation Act Death Gratuity Payment under 5 U.S.C. Â§ 8102a	CA 40 mjs (2) jv 3-12-12 feewc edits.docx	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: 2,600

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	Previously Approved
Annual Number of Responses for this IC	2,600	2,600
Annual IC Time Burden (Hours)	650	650
Annual IC Cost Burden (Dollars)	0	0

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.