Claim for Compensation by a Dependent Information Reports

Claim for Compensation by a Dependent Information Reports

OMB: 1240-0013

IC ID: 13841

Information Collection (IC) Details

View Information Collection (IC)

Claim for Compensation by a Dependent Information Reports
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 10.410 20 CFR 10.413 20 CFR 10.417 20 CFR 10.7 20 CFR 10.535 20 CFR 10.537 20 CFR 10.105

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CA-1031 Claimant Support of Dependent CA-1031 revised 2016.pdf https://www.dol.gov/owcp/dfec/regs/compliance/forms.htm Yes Yes Printable Only
Form CA-1074 Request for Clarification of CA-5b CA-1074 Revised 2016.pdf https://www.dol.gov/owcp/dfec/regs/compliance/forms.htm Yes Yes Printable Only
Form and Instruction CA-5 Claim for Compensation by Widow, Widower, and/or Children CA-5 working.pdf https://www.dol.gov/owcp/dfec/regs/compliance/forms.htm Yes Yes Fillable Printable
Form and Instruction CA-5b Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandchildren CA-5b working.pdf https://www.dol.gov/owcp/dfec/regs/compliance/forms.htm Yes Yes Fillable Printable
Other-null Deathcompdue for revision 2016 mjs revised 5-13-16 final mjs 7-01-2016.rtf No   Paper Only
Other-null StudentDependency revision may 13 2016 mjs final 7-01-2016.rtf No   Paper Only

Income Security Survivor Compensation

DOL/GOVT-1  67 FR 16826

1,675 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,675 0 0 -1,245 0 2,920
Annual IC Time Burden (Hours) 964 0 0 -607 0 1,571
Annual IC Cost Burden (Dollars) 871 0 0 -560 0 1,431

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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