Information Collection

Claim for Compensation by a Dependent Information Reports

IC 13841 under ICR 201910-1240-002 · OMB 1240-0013.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0013 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CA-1031 Claim for Compensation by a Dependent Information Reports	Form
Deathcompdue for revision 2016 mjs revised 5-13-16 final mjs 7-01-2016.rtf	Other-null
StudentDependency revision may 13 2016 mjs final 7-01-2016.docx	Other-null
CA-1031 Claimant Support of Dependent CA-1031 revised 2016.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form
CA-1074 Request for Clarification of CA-5b CA-1074 Revised 2016.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form
CA-5 Claim for Compensation by Widow, Widower, and/or Childre CA-5 working.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction
CA-5b Claim for Compensation by Parents, Brothers, Sisters, Gr CA-5b working.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction

IC Title:

Claim for Compensation by a Dependent Information Reports

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 10.535 20 CFR 10.537 20 CFR 10.7 20 CFR 10.410 20 CFR 10.413 20 CFR 10.417 20 CFR 10.105

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CA-1031	Claimant Support of Dependent	CA-1031 revised 2016.pdf	https://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	Yes	Printable Only
Form	CA-1074	Request for Clarification of CA-5b	CA-1074 Revised 2016.pdf	https://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	Yes	Printable Only
Form and Instruction	CA-5	Claim for Compensation by Widow, Widower, and/or Children	CA-5 working.pdf	https://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	Yes	Fillable Printable
Form and Instruction	CA-5b	Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandchildren	CA-5b working.pdf	https://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	Yes	Fillable Printable
Other-null			Deathcompdue for revision 2016 mjs revised 5-13-16 final mjs 7-01-2016.rtf		No		Paper Only
Other-null			StudentDependency revision may 13 2016 mjs final 7-01-2016.docx		No		Paper Only

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records

Title: DOL/GOVT-1

FR Citation: 81 FR 47418

Number of Respondents: 933

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	933	-742	1,675
Annual IC Time Burden (Hours)	800	-164	964
Annual IC Cost Burden (Dollars)	541	-330	871

Documents for IC

table that charts IC Documents
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.