OMB control number
Claim for Continuance of Compensation (CA-12)
OMB 1240-0015 ยท DOL/OWCP.
OMB 1240-0015
This form is used to obtain information from eligible survivors receiving death benefits for an extended period of time. This information is necessary to ensure that compensation being paid is accurate.
The latest form for Claim for Continuance of Compensation (CA-12) expires 2027-01-31 and is listed under ICR 202310-1240-001.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form CA-12 Claim for Continuance of Compensation | Form and Instruction |
| 60-day FRN (1240-0015) 8.7.23.pdf | Supplementary Document |
| dol govt - 1.pdf | Supplementary Document |
| 5 USC 8133.pdf | Supplementary Document |
| National Average Weekly Wage for non-supervisory workers on private non-agriculture payrolls as computed by BLS as of April 2023.pdf | Supplementary Document |
| OPM Salary Table 2023. RUS.pdf | Supplementary Document |
 Supporting Statement 1240-0015 2023_MN nmh clean version..docx | Supporting Statement A |
 Claim for Continuance of Compensation |
Form and Instruction |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202310-1240-001 | Extension without change of a currently approved collection | 2023-12-05 | Approved without change | |
| 202005-1240-003 | Extension without change of a currently approved collection | 2020-10-16 | ||
| 202002-1240-004 | No material or nonsubstantive change to a currently approved collection | 2020-02-21 | Approved without change | |
| 201703-1240-005 | Revision of a currently approved collection | 2017-07-31 | Approved without change | |
| 201402-1240-001 | Revision of a currently approved collection | 2014-06-13 | Approved without change | |
| 201011-1240-003 | Revision of a currently approved collection | 2011-05-03 | Approved without change | |
| 201003-1240-015 | Extension without change of a currently approved collection | 2010-03-12 | Approved without change |