ca-40 CA-40 Designation of a Recipient of the Federal Employee

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U.S. DEPARTMENT OF LABOR

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Office of Workers’ Compensation Programs
Division of Federal Employees' Compensation
OMB Number: 1240-0017
Expiration Date: 07/21/2023

CA-40 Designation of a Recipient of the Federal Employees' Compensation Act
Death Gratuity Payment under 5 U.S.C. § 8102a
A. Identifying Information about the Federal Employee
Name (Last, First, Middle)

Date of Birth

Department or Agency in which presently employed (include
Bureau, Division, and phone number)

Social Security Number
Location (City, State, and ZIP code)

B. Designating an Alternate Order of Precedence
If you have no surviving spouse or child eligible to receive the death gratuity, and you wish to designate
any one or more of your parents or brothers or sisters to receive specific shares (%) of the gratuity,
please fill in the required boxes below. If you designate more than one individual and do not indicate a
share for each individual, the death gratuity will be paid to those individuals in equal shares. An
individual designated below must be living at the time of payment to receive any or all of your
death gratuity.
First Name, middle initial, and last name of
each designee

Address (including ZIP code) of each
designee

Relationship to you
(must be parent,
brother, or sister)

Share to be
provided to each
designee

Note: Effective December 31, 2011, employing agencies are required to notify your spouse if you have
designated all or a portion of the death gratuity to someone other than your spouse. Section 1121 of
Public Law 112-81.
If you have a disability and are in need of communication assistance (such as alternate formats or sign
language interpretation), accommodations and/or modifications, please contact OWCP. See Instructions
for additional details.

CA-40 (Rev. 05-16)

C. Additional Alternate Beneficiary Designation Provision
In addition to or instead of the above, you may designate another person or persons to receive all or a
portion of your death gratuity. If you do not designate anyone in this section, 100% of the death gratuity
will be disbursed according to the order of precedence provided by statute and described in the
instructions. Under this provision, you may designate up to 100% of the death gratuity in 10%
increments. If you utilize this designation provision, the undesignated portion of the death gratuity will be
disbursed as specified in the order of precedence. An individual designated below must be living at
the time of payment to receive any or all of your death gratuity.
First Name, middle initial, and last name
of each designee

Address (including Zip Code) of each
designee

Share to be provided to each designee
(must be in 10% increments)

D. Statement of Federal Employee Completing this Form
I understand that this Designation is not valid unless delivered to an official of the employing establishment
prior to the death of the employee and that it will stay in effect unless it is cancelled.
I understand that if this Designation is invalid for any reason, the death gratuity will be paid according to the
next most recent valid designation. In the event no valid designation has been made, the death gratuity will
be paid according to the order of precedence in as described in the instructions (5 U.S.C. § 8102a).
I am canceling any and all previous Designations of the death gratuity payment under 5 U.S.C. § 8102a
and am now designating the recipients named above. NOTE: If this notice is completed by the

employee, it must be sent to the employing agency, signed by the employee's
supervisor and retained by the employing agency in order to be valid.

Signature of the Federal Employee. This form is not valid unless the employee signs in this
box and enters a date in the box to the right.

Date (mm/dd/yyyy)

CA-40 PAGE 2 (Rev. 05-16)

E. Signature of the Employing Establishment Official Receiving this Form
I have received this form from the federal employee who has signed above. To the best of my knowledge
and belief, the employee has filled out this form completely in accordance with the instructions on the form.
Signature of the Employing Establishment Official. This form is not valid unless, prior to
the death of the employee, the official signs in this box and enters a date in the box to
the right.

Date (mm/dd/yyyy)

Printed Name, Title, Address and phone and fax numbers of the Employing Establishment Official.

NAME:
TITLE:
ADDRESS:
PHONE NUMBER:
FAX NUMBER:

PRIVACY ACT STATEMENT
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees’
Compensation Act (FECA), as amended and extended (5 U.S.C. 8101, et seq.) including the amendment to the Federal Employees'
Compensation Act, 5 U.S.C. § 8102a – Death Gratuity is administered by the Office of Workers' Compensation Programs of the U.S.
Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2) Information
which the Office has will be used to determine eligibility for and the amount of benefits payable under the FECA, and may be verified
through computer matches or other appropriate means. (3) Information may be given to the Federal agency which employed the
claimant at the time of injury in order to verify statements made, answer questions concerning the status of the claim, verify billing,
and to consider issues relating to entitlement to benefits or other relevant matters. (4) Information may be given to Federal, state
and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA, to determine whether
benefits are being paid properly, including whether prohibited dual payments are being made, and, where appropriate, to pursue
salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection Act. (5)
Disclosure of the claimant's social Security number (SSN) or tax identifying number (TIN) on this form is mandatory (Executive
Order 9397, dated November 22, 1943). The SSN (and/or TIN), and other information maintained by the Office, may be used for
identification, to support debt collection efforts carried on by the Federal government, and for other purposes required or authorized
by law. (6) Failure to disclose all requested information may delay the processing of the claim or the payment of benefits, or may
result in an unfavorable decision or reduced level of benefits.
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 number. Public reporting burden for this collection of information is estimated to average 15 minutes
per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing
and reviewing the collection of information. The obligation to respond to this collection is voluntary (5. U.S.C. 8102a). Send
comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to the Office of Workers' Compensation Programs, U.S. Department of Labor, Room S3524, 200 Constitution Avenue, N.W.,
Washington, D.C. 20210, and reference the OMB Control Number 1240-0017. Note: Do not submit the completed claim form to
this address.

CA-40 PAGE 3 (Rev. 05-16)

CA-40 Instructions Designation of a Recipient of the Death Gratuity
under 5 U.S.C. § 8102a
INSTRUCTIONS

The Death Gratuity Payment
If a federal civilian employee or an employee of a nonappropriated fund instrumentality dies of injuries incurred in
connection with his or her service with an Armed Force in a contingency operation, his or her eligible beneficiaries
may receive a death gratuity payment of up to $100,000. The gratuity is a one-time payment disbursed to the
highest ranked survivor or survivors of the employee according to the order of precedence below or in accordance
with the most recent valid alternate beneficiary designations above. Federal employees may use this form to
designate alternate beneficiaries or to modify the order of precedence of payment of this benefit.
NOTE: Effective December 31, 2011, employing agencies are required to notify your spouse, if one exists, if you
designate all or a portion of the death gratuity to someone other than your spouse.
NOTE TO EMPLOYING AGENCIES: If the federal employee completing this form has a spouse, the agency is
required effective December 31, 2011 to notify that spouse if the federal employee designates anyone other than
that spouse to receive all or a portion of the FECA death gratuity pursuant to 5 U.S.C. § 8102a.
Request for Accommodations or Auxiliary Aids and Services
If you have a disability, Federal law gives you the right to receive help from the OWCP/DFEC in the form of
communication assistance, accommodation(s) and modification(s) to aid you in the claims process. For example, we
will provide you with the copies of documents in alternate formats, communication services such as sign language
interpretation, or other kinds of adjustments or changes to accommodate your disability. Please contact our office or
your OWCP claims examiner to ask about this assistance.
You do not need to fill out this form if you are satisfied that 100% of the gratuity will be paid entirely to the
survivor highest on the list below:
1.Your surviving spouse.
2. If you do not have a surviving spouse, your death gratuity will be paid to your children, in equal shares.
Your children include any adopted children, stepchildren who are part of your household at the time of
death, and any illegitimate children, subject to the following limitation. An illegitimate child of a male
decedent only qualifies as an eligible survivor if the child:

•
•
•

has been acknowledged in writing signed by the decedent;
has been judicially determined, before the decedent's death, to be his child;
has been otherwise proved, by evidence satisfactory to the employing agency, to be a child of the
decedent; or
• is a child to whose support the decedent had been judicially ordered to contribute.
3. If you have no surviving spouse or eligible child, you can choose to divide your death gratuity among your
parents or brothers or sisters, as you designate in section B of the form.

•

The term “parents” includes adoptive parents and persons who stood in loco parentis to the
decedent for not less than one year before the decedent became an employee covered by this
provision, but the term is limited to one father or mother or their counterparts.
• “Brothers” and “sisters” include half-brothers and half-sisters, and brothers and sisters through
adoption.
4. If you have no surviving spouse or eligible child and do not designate anyone in section B of the form, your
death gratuity will be paid to your living parent or parents, in equal shares.
5. If you have no surviving spouse, eligible child, or living parent and do not designate anyone in section B of the
form, your death gratuity will be paid to your brothers and sisters, in equal shares.
6. If you wish, you may use Section C to designate all or a portion of this benefit to an alternate beneficiary(ies).
In order for such a designation to be valid, the form must be otherwise valid and you must designate a
percentage in 10% increments, the alternate must be alive, and the alternate beneficiary must be a person.

CA-40 PAGE 4 (Rev. 05-16)