Letter to Dependents to Verify Claimant Support (CA-1031)

U. S. Department of Labor

Office of Workers’ Compensation Programs
Washington, D.C. 20210
File Number:
OMB NO: 1240-0013
Expiration Date: 07/31/2023

Sender Address:
Phone:
Date:
Date of Injury:
Employee:
Dep(s):

To Address:
Dear:
To help us reach a decision regarding a claim for compensation filed by
_________________, please furnish the information requested below. This information
is required to obtain or retain a benefit (5 U.S.C. 8101 et seq.).
1. State your relationship to employee (that is, wife, husband, natural parent or guardian
of dependent(s) named above, or parent of employee).
______________________________________________________________________
2. State the amount of money that employee regularly contributes to your support or to
the support of the dependent(s) named above. State how often the contributions are
made – weekly, monthly, etc. If contributions are not made at regular intervals or in the
form of money, please explain.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

If you have a disability and are in need of communication assistance (such as alternate
formats or sign language interpretation), accommodation(s) and/or modification(s),
please contact OWCP.

CA-1031
Revised January 2013

3. Approximate date such contributions were first made:
______________________________________________________________________
4. If you are natural parent or legal guardian of the dependent(s) named above, give the
age and relationships to the employee of each dependent.
______________________________________________________________________
______________________________________________________________________

5. If you are a parent of the employee, state the source and amount of all your other
income. If none, so state.
______________________________________________________________________

______________________________________________________________________

I certify that each and every statement made above is true to the best of my knowledge.
I further understand that any person who knowingly makes any false statement,
misrepresentation, concealment of fact, or any other act of fraud to obtain compensation
as provided by the FECA or who knowingly accepts compensation to which that person
is not entitled is subject to felony criminal prosecution and may, under appropriate
criminal provisions, be punished by a fine or imprisonment or both.
__________________________________________
Signature

____________
Date

Sincerely,

Name of Signer:
Title:
CC Addresses:

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CA-1031
Revised January 2013

Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond
to a collection of information unless such collection displays a valid OMB control
number. Public reporting burden for this collection of information is estimated to average
20 minutes per response, including time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. The authority for requesting this information is 5 U.S.C.
8101 et seq. The information will be used to determine entitlement to benefits.
Furnishing the requested information is required for the claimant to obtain or retain a
benefit. Send comments regarding the burden estimate or any aspect of this collection
of information, including suggestions for reducing this burden, to the Office of Workers'
Compensation Programs, Department of Labor, Room S-3229, 200 Constitution Avenue,
NW, Washington, DC 20210, and reference the OMB Control Number 1240-0013. Note:
please do not send the completed form to this office; rather, send it to the address
shown on the letterhead.

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CA-1031
Revised January 2013