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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Claim for Compensation by a Dependent Information Reports
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
20 CFR 10.410
20 CFR 10.413
20 CFR 10.417
20 CFR 10.7
20 CFR 10.535
20 CFR 10.537
20 CFR 10.105
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CA-1031
Claimant Support of Dependent
CA-1031 revised 2016.pdf
https://www.dol.gov/owcp/dfec/regs/compliance/forms.htm
Yes
Yes
Printable Only
Form
CA-1074
Request for Clarification of CA-5b
CA-1074 Revised 2016.pdf
https://www.dol.gov/owcp/dfec/regs/compliance/forms.htm
Yes
Yes
Printable Only
Form and Instruction
CA-5
Claim for Compensation by Widow, Widower, and/or Children
CA-5 working.pdf
https://www.dol.gov/owcp/dfec/regs/compliance/forms.htm
Yes
Yes
Fillable Printable
Form and Instruction
CA-5b
Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandchildren
CA-5b working.pdf
https://www.dol.gov/owcp/dfec/regs/compliance/forms.htm
Yes
Yes
Fillable Printable
Other-
Deathcompdue for revision 2016 mjs revised 5-13-16 final mjs 7-01-2016.rtf
No
Paper Only
Other-
StudentDependency revision may 13 2016 mjs final 7-01-2016.rtf
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Income Security
Subfunction:
Survivor Compensation
Privacy Act System of Records
Title:
DOL/GOVT-1
FR Citation:
67 FR 16826
Number of Respondents:
1,675
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
1,675
0
0
-1,245
0
2,920
Annual IC Time Burden (Hours)
964
0
0
-607
0
1,571
Annual IC Cost Burden (Dollars)
871
0
0
-560
0
1,431
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.