Death Gratuity

Forms and Documents

Document Name	Status
Form ca-42 Death Gratuity Official Notice of Employees' Death Form and Instruction	Modified
Form ca-41 Death Gratuity Claim for Survivor Benefits Form and Instruction	Modified
Form ca-40 Death Gratuity Beneficiary Designation Form and Instruction	Modified
1240-0017 Supptng Stmt final.docx Supporting Statement A	2020-04-02
81 Fed. Reg 47418 (July 21, 2016).pdf Supplementary Document	2020-01-08
Death Gratuity Information-DFEC website.doc Supplementary Document	2019-09-27
20 cfr 10.909 and 10.911.docx Supplementary Document	2019-09-27
Salary Table Cleveland 2019.pdf Supplementary Document	2019-09-27
BLS summary table 2019.docx Supplementary Document	2019-09-27

IC Document Collections

IC ID	Document Title	Status
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: 201908-1240-001
Status: Active	Previous ICR Reference No: 201603-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Death Gratuity
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/14/2020
	Date Received in OIRA: 04/14/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2023	36 Months From Approved
Responses	4	0	0
Time Burden (Hours)	1	0	0
Cost Burden (Dollars)	1	0	0

---

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. 112 - 81 1121 Name of Law: National Defense Authorization Act for Fiscal Year 2012
   PL: Pub.L. 110 - 181 1105 Name of Law: National Defense Authorization Act for Fiscal Year 2008
   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:
	84 FR 59652	11/05/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 20305	04/10/2020
Did the Agency receive public comments on this ICR? No

---

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

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

	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	4	0	0	0	-258	262
Annual Time Burden (Hours)	1	0	0	0	-66	67
Annual Cost Burden (Dollars)	1	0	0	0	-2	3

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: This reinstatement is being made without a change to bring back into compliance as it has expired. The number of claims received for death gratuity has significantly decreased since the implementation of U.S.C. § 8102a in 2008. It is anticipated these claims will continually remain low since OWCP will pay death gratuity benefits minus the amount of any death gratuity payments that have been paid under any other law of the United States based on that same death. Only 1 agency report of death gratuity claim (CA-42) was received between 2016 and 2018, and there were two designated beneficiaries as noted on the CA-40. Both of these beneficiaries filed a CA-41 with OWCP. As a reminder, 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 and submit it to their employing agency prior to deployment or may choose to rely on a designation from an earlier deployment. However, the completed CA-40 must be submitted to OWCP when a claim for death gratuity benefits is filed. Therefore, the previous approved number of annual respondents 262 is now 4, which represents a decrease in 258 respondents. The previously approved number for burden hours was 67; the requested number now is 1, which is a decrease of 66.

---

Annual Cost to Federal Government: $97

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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? No

---

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: 04/14/2020

---