Claim for Continuance of Compensation

Claim for Continuance of Compensation (CA-12)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0015 can be found here:

Documents and Forms

Document Name Document Type
Form CA-12 Claim for Continuance of Compensation Form and Instruction
CA-12 Claim for Continuance of Compensation Under the Federal ca-12.pdf www.dol.gov/owcp/regs/compliance/ca-12.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Claim for Continuance of Compensation	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 10.126

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CA-12	Claim for Continuance of Compensation Under the Federal Employees' Compensation ACt	ca-12.pdf	https://www.dol.gov/owcp/regs/compliance/ca-12.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title: DOL/GOVT-1	FR Citation: 67 FR 16817

Number of Respondents: 3,552	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 1 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,552	3,552
Annual IC Time Burden (Hours)	295	295
Annual IC Cost Burden (Dollars)	1,847	1,847

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.