Information Collection

Death Gratuity Claim for Survivor Benefits

IC 190296 under ICR 201908-1240-001 · OMB 1240-0017.

⚠️ Notice: This information collection may be referencing outdated material.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-41 Death Gratuity Claim for Survivor Benefits Form and Instruction
ca-41 Claim for Survivor Benefits under FECA Section 8102a Dea CA-41.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 Claim for Survivor Benefits	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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-41	Claim for Survivor Benefits under FECA Section 8102a Death Gratuity	CA-41.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: 81 FR 47418

Number of Respondents: 2	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	2	-4	6
Annual IC Time Burden (Hours)	1	-1	2
Annual IC Cost Burden (Dollars)	1	-2	3

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.