Claim for Compensation by a Dependent Information Reports

Forms and Documents

Document Name	Status
Form CA-5 Claim for Compensation by a Dependent Information Reports Form and Instruction	Modified
Section 8110.doc Supplementary Document	2013-06-18
Salary Table 1240-0013.pdf Supplementary Document	2013-06-18
BLS Average hours and earnings production and nonsupervisory employees.pdf Supplementary Document	2013-06-18
dol-govt-1.doc Supplementary Document	2013-06-18
eCFR — Code of Federal Regulations.mht Supplementary Document	2013-06-18
SS 1240-0013 supporting statement.doc Supporting Statement A	2013-06-18

IC Document Collections

IC ID	Document Title	Status
13841	Claim for Compensation by a Dependent Information Reports Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0013	ICR Reference No: 201302-1240-001
Status: Historical Active	Previous ICR Reference No: 201004-1240-013
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Claim for Compensation by a Dependent Information Reports
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/19/2013
	Date Received in OIRA: 07/01/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2016	36 Months From Approved	08/31/2013
Responses	2,920	0	1,358
Time Burden (Hours)	1,571	0	870
Cost Burden (Dollars)	1,431	0	638

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Abstract: These reports request information from the survivors of deceased Federal employees which verify dependents status when making a claim for benefits and on a periodic basis in accepted claims. Some of the forms are used to obtain information on claimed dependents in disability cases.

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Authorizing Statute(s): US Code: 5 USC 8101 et seq. Name of Law: Augmented Compensation for Dependents
  

Citations for New Statutory Requirements: None

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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:
	78 FR 15742	03/12/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 39014	06/28/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Claim for Compensation by a Dependent Information Reports	CA-5, CA-5B, CA-1031, CA-1074	Claim for Compensaion by Widow, Widower, and/or Children ,   Claimant Support of Dependent ,   Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandshildren ,   Request for Clarification of CA-5b

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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	2,920	1,358	0	0	1,562	0
Annual Time Burden (Hours)	1,571	870	0	0	701	0
Annual Cost Burden (Dollars)	1,431	638	0	0	793	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: The estimated number of annual respondents (2,920) is an increase of 1,562 from the previous request of 1,358. The estimate in burden hours (1,571) is an increase of (701) from the previously approved 870. Additionally, the estimated cost burden of $1,431 is $793 more than the previously requested of $638. The adjustment in the number of respondents and the burden hours are due in part to having a better accountability of tracking receipt of responses via a computer data base and in particular, with an emphasis in our program to send out letters to a claimant's estate to reclaim compensation in the event of death, i.e., the Comp Death Due letters. Further, costs burden has increased as a result of the respondents previously indicated and the fact that mailing costs is now 49 cents versus the previously requested of 47 cents. As a result of the Department of Treasury now requiring all federal benefits payments to be made electronically, the CA-5 and CA-5b were revised to include space on the forms for claimants to complete information related to direct deposit. The instructions to these forms regarding this requirement were also added. Additionally, all of the form letters/forms were revised to include an accommodation statement to inform claimants who have mental or physical limitations to contact DFEC if further assistance is needed with the claims process. This language is placed beneath the Public Burden Statement on the CA-5 and 5b, and as a footer on the remaining form letters.

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Annual Cost to Federal Government: $30,351

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: 07/01/2013

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