View Information Collection (IC)

View Information Collection (IC)

IC Title:	Death Gratuity Claim for Survivor Benefits	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

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	ca-41	Claim for Survivor Benefits under FECA Section 8102a Death Gratuity	CA-41.pdf	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title: dol/govt-1	FR Citation: 67 FR 16826

Number of Respondents: 6	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	6	0	0	-5	0	11
Annual IC Time Burden (Hours)	2	0	0	-1	0	3
Annual IC Cost Burden (Dollars)	3	0	0	-2	0	5

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.