CA-1074 Letter to Parents in Death Claim Development

U. S. Department of Labor

Office of Workers’ Compensation Programs
Washington, D.C. 20210

OMB NO: 1240-0013
Expiration Date: 07/31/2023

Sender Address:
Phone:
Date:
Date of Injury:
Employee:
To Address:
Dear:
Additional information is needed in support of your claim for dependency compensation.
Please supply answers to all questions on the attached questionnaire and complete the
affidavit which follows.
Further consideration will be given to your claim on receipt of this evidence. This
information is required to obtain a benefit (5 U.S.C. 8101 et seq.).
Sincerely,

Name of Signer:
Title:
CC Addresses:

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-1074
Revised January 2013

EVIDENCE REQUIRED IN SUPPORT OF A DEPENDENCY CLAIM

1. State the inclusive dates the deceased was employed during the 12 months
immediately preceding death. Give the names and addresses of his employers
during that period, the rate of pay, and the total amount earned in each job.

2. State whether the deceased was living away from home at any time during the
12-month period before death. If so, give the inclusive dates. Forward any
canceled checks, money order receipts, letters, or other evidence of the fact that
the deceased contributed to your support during that time.

3. If you are now employed, give your Social Security account number, the name of
your employer, your wages, and your occupation. If not now employed, explain
why.

4. State whether your husband (or wife) survives. If he is employed, give his Social
Security account number, employer's name, amount of wages, and occupation.
If not employed, state why.

5. Furnish names and relationship to you of all persons who lived in the same
household with you during the year preceding the death, and the monthly amount
contributed by each toward support of the household.

6. State what support you have received from your surviving children since the
death of the decedent. If they are now living with you and are not contributing to
your support, state why.

7. List all real or personal property owned by you and your husband (wife), including
money on deposit in the bank or invested, and the income from all property and
investments.

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CA-1074
Revised January 2013

8. Submit a copy of the record of birth of the deceased.

9. Submit an affidavit from at least two persons (preferably not related to you or to
the decedent) who have actual knowledge of whether the decedent contributed
to your support during the 12 months before death; whether you were dependent
on these contributions for your livelihood; why this was true and how they (the
affiants) know it to be true.

I certify that the information give in response to his questionnaire is true to the best of my
knowledge and belief. 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

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_______________
Date

CA-1074
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 estimated to be 60
minutes per response, including time for reviewing instructions, searching existing data
sources, gathering and maintaining the date 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-1074
Revised January 2013