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Death Gratuity Beneficiary Designation
Death Gratuity
OMB: 1240-0017
IC ID: 190277
OMB.report
DOL/OWCP
OMB 1240-0017
ICR 201908-1240-001
IC 190277
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0017 can be found here:
2023-05-15 - Extension without change of a currently approved collection
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
View Information Collection (IC)
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
Federal Enterprise Architecture Business Reference Module
Line of Business:
Workforce Management
Subfunction:
Worker Safety
Privacy Act System of Records
Title:
DOL/Govt -1
FR Citation:
81 FR 47418
Number of Respondents:
1
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
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
0
0
-249
250
0
Annual IC Time Burden (Hours)
0
0
0
-63
63
0
Annual IC Cost Burden (Dollars)
0
0
0
0
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.