Claim for Compensation by a Dependent Information Reports

OMB 1240-0013

OWCP is requesting an address change to the Letter to Dependents to Verify Claimant Support (CA-1031), Claim for Compensation by Surviving Spouse and/or Grandchildren (CA-5), Claim for Compensation by Parents, Brothers, Sisters, Grandparents or Grandchildren (CA-5b) and the Letter to Parents in Death Claim Development (CA-1074). The forms included in this package are used to request information for entitlement to claim benefits under the Federal Employees’ Compensation from federal employees/ their dependents/ survivors, to prove continued eligibility for benefits, to show entitlement to remaining compensation payments of a deceased employee, and to show dependency.

The latest form for Claim for Compensation by a Dependent Information Reports expires 2023-07-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
1240-0013 Supporting Statement--final.docx Supporting Statement A
81 Fed. Reg. 47418 (July 21, 2016).pdf Supplementary Document
b-8 table average hourly and weekly earnings of production and nonsupervisory employees on nonprivate nonfarm payrolls, seasonally adjusted.docx Supplementary Document
20 cfr 10.7 etc.docx Supplementary Document
2023 OPM Salary Table Rus.pdf Supplementary Document
5 usc 8110 augmented compensation for dependents.docx Supplementary Document
Claim for Compensation by a Dependent Information Reports Other-

All Historical Document Collections

202302-1240-003 Approved with change	Extension without change of a currently approved collection	2023-05-09
202008-1240-047 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-10-20
201910-1240-002 Approved without change	Reinstatement without change of a previously approved collection	2020-04-15
201602-1240-003 Approved without change	Revision of a currently approved collection	2016-08-24
201302-1240-001 Approved without change	Revision of a currently approved collection	2013-07-01
201004-1240-013 Approved without change	Extension without change of a currently approved collection	2010-05-28
201003-1240-013 Approved without change	Extension without change of a currently approved collection	2007-03-01