Information Collection Request
Death Gratuity
ICR 202304-1240-001 · OMB 1240-0017 · Received in OIRA
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 1240-0017 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form ca-42 Death Gratuity Official Notice of Employees' Death |
Form and Instruction | Modified | Repair queued |
| Form ca-41 Death Gratuity Claim for Survivor Benefits |
Form and Instruction | Modified | Repair queued |
| Form ca-40 Death Gratuity Beneficiary Designation |
Form and Instruction | Modified | Repair queued |
 1240-0017 Supporting Statement Death Gratuity FINAL.docx |
Supporting Statement A | Uploaded 2023-05-05 | Repair queued |
 81 Fed. Reg. 47418 (July 21, 2016).pdf |
Supplementary Document | Uploaded 2023-04-06 | Repair queued |
| Death Gratuity 4.2023.docx |
Supplementary Document | Uploaded 2023-04-06 | Repair queued |
| 20 cfr 10.909 and 10.911 4.2023.docx |
Supplementary Document | Uploaded 2023-04-06 | Repair queued |
| 2022 opm salary table cleveland.pdf |
Supplementary Document | Uploaded 2023-04-07 | Repair queued |
| BLS Data.pdf |
Supplementary Document | Uploaded 2023-04-07 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 190297 |  Death Gratuity Official Notice of Employees' Death |
Form and Instruction | Modified | |
| 190296 | Death Gratuity Claim for Survivor Benefits |
Form and Instruction | Modified | |
| 190277 | Death Gratuity Beneficiary Designation |
Form and Instruction | Modified |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | DOL/OWCP |
| OMB Control No | 1240-0017 |
| Type of Information Collection | Extension without change of a currently approved collection |
| Previous ICR Reference No | 201908-1240-001 |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |