Death Gratuity

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form ca-42 Death Gratuity Official Notice of Employees' Death	Form and Instruction	Modified	Available
Form ca-41 Death Gratuity Claim for Survivor Benefits	Form and Instruction	Modified	Repair queued
Form ca-40 Death Gratuity Beneficiary Designation	Form and Instruction	Modified	Repair queued
20 cfr 10.909 and 10.911.docx	Supplementary Document	Uploaded 2016-08-10	Available
BLS summarytable_201512.pdf	Supplementary Document	Uploaded 2016-06-13	Available
DOL GOVT-1.doc	Supplementary Document	Uploaded 2016-06-13	Available
Salary Table Cleveland 1240-0017.pdf	Supplementary Document	Uploaded 2016-06-13	Available
National Average Weekly Wage for production or non-supervisory workers on private nonagricultural payrolls.pdf	Supplementary Document	Uploaded 2013-01-29	Available
Death Gratuity Information-DFEC website (2)[1].doc	Supplementary Document	Uploaded 2013-01-29	Available
Supporting Statement 1240-0017 2016.docx	Supporting Statement A	Uploaded 2016-08-11	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
190297	Death Gratuity Official Notice of Employees' Death	Form and Instruction	Modified
190296	Death Gratuity Claim for Survivor Benefits	Form and Instruction	Modified
190277	Death Gratuity Beneficiary Designation	Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0017	ICR Reference No: 201603-1240-001
Status: Historical Active	Previous ICR Reference No: 201301-1240-002
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Death Gratuity
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: 12/12/2016
	Date Received in OIRA: 08/17/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2019	36 Months From Approved	12/31/2016
Responses	262	0	272
Time Burden (Hours)	67	0	70
Cost Burden (Dollars)	3	0	5

---

Abstract: The National Defense Authorization Act for Fiscal Year 2008, Public Law 110-181, was enacted on January 28, 2008. Section 1105 of P.L. 110-181 amended the Federal Employees' Compensation Act (FECA) creating a new section, 5 U.S.C. § 8102a effective upon enactment. This section establishes a FECA death gratuity benefit of up to $100,000 for eligible beneficiaries of federal employees and Non-Appropriated Fund Instrumentality (NAFI) employees who die from injuries incurred in connection with service with an Armed Force in a contingency operation. 5 U.S.C.§ 8102a also permits agencies to authorize retroactive payment of the death gratuity for employees who died on or after October 7, 2001 in service with an Armed Force in the theater of operations of Operation Enduring Freedom and Operation Iraqi Freedom. 5 U.S.C. § 8102a also allows federal employees to vary the order of precedence of beneficiaries or to name alternate beneficiaries 20 CFR 10.909, and 10.911 provides that the CA-40, CA-41, and CA-42 are the forms to be used to designate beneficiaries and initiate the payment process for death gratuity benefits. Form CA-40 is an optional form that requests the information necessary from the employee to accomplish this variance and to name alternate beneficiaries only if the employee wishes to do so. Form CA-41 provides the means for those named beneficiaries and possible recipients to file claims for those benefits and requests information from such claimants so that OWCP may determine their eligibility for payment. Further, the statute and regulations require agencies to notify OWCP immediately upon the death of a covered employee. CA-42 provides the means to accomplish this notification and requests information necessary to administer any claim for benefits resulting from such a death.

---

Authorizing Statute(s): US Code: 5 USC 8102a Name of Law: Amendment to the FECA, Death Gratuity
   PL: Pub.L. 110 - 181 1105 Name of Law: National Defense Authorization Act for Fiscal Year 2008
   PL: Pub.L. 112 - 81 1121 Name of Law: National Defense Authorization Act for Fiscal Year 2012
   US Code: 5 USC 8145 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8149 Name of Law: Federal Employees' Compensation Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 21905	04/13/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 54852	08/17/2016
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Death Gratuity Beneficiary Designation	ca-40	CA-40 Designation of a Recipient of the Federal Employees' Compensation Act Death Gratuity Payment under 5 U.S.C. § 8102a
Death Gratuity Official Notice of Employees' Death	ca-42	Official Notice of Employees' Death for Purposes of FECA Section 8102a Death Gratuity
Death Gratuity Claim for Survivor Benefits	ca-41	Claim for Survivor Benefits under FECA Section 8102a Death Gratuity

---

ICR Summary of Burden

table that charts list 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	262	272	0	0	-10	0
Annual Time Burden (Hours)	67	70	0	0	-3	0
Annual Cost Burden (Dollars)	3	5	0	0	-2	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 number of claims received for death gratuity varies from year to year. Only 6 death gratuity claims were received between 2013 and 2015. As these operations have winded down since their inception, the number of claims have decreased. Furthermore, as the CA-40 is an optional form, used only when an employee wishes to vary the order or preference or designate an alternate beneficiary for payment, not all employees choose to fill out this form prior to deployment or may choose to rely on a designation from an earlier deployment, so the number of people filling out this form varies greatly year to year. Therefore, the previous approved number of annual respondents 272, is now 262, which represents a decrease in 10 respondents. The previously approved number for burden hours was 70; the requested number now is 67, which is a decrease of 3. Likewise, the costs burden for maintenance and reporting costs (postage and envelope) decreased from $5.00 to $3.00, which is a decrease of $2.00.

---

Annual Cost to Federal Government: $417

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

---

Common Form ICR:  No

---

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: 08/17/2016

---