Death Gratuity Beneficiary Designation

Death Gratuity

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction

Information Collection (IC) Details

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:

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. § 8102a	CA-40.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: 250	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	63	63
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.