Information Collection

Death Gratuity Claim for Survivor Benefits

IC 190296 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⚠️ Notice: This information collection may be referencing outdated material.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-41 Death Gratuity Claim for Survivor Benefits	Form and Instruction
ca-41 Claim for Survivor Benefits under FECA Section 8102a Dea CA-41-new-pending.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction

IC Title:

Death Gratuity Claim for Survivor Benefits

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

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-41	Claim for Survivor Benefits under FECA Section 8102a Death Gratuity	CA-41-new-pending.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: 25

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	25	25
Annual IC Time Burden (Hours)	6	6
Annual IC Cost Burden (Dollars)	12	12

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.