CA-5 Claim for Compensation by Surviving Spouse and/or Childr

Claim for Compensation by a Dependent Information Reports

1240-0013 Claim for Comp by Surviving Spouse and or Children (CA-5)

Claim for Compensation by a Dependent Information Reports

OMB: 1240-0013

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1240-0013 can be found here:

2023-05-09 - Extension without change of a currently approved collection

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File Type	application/pdf
File Title	CA-5
Subject	Claim for Compensation by Widow, Widower, and/or Children
File Modified	2020-08-13
File Created	2013-08-20