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OMB Control No: 1240-0017	ICR Reference No: 202604-1240-002
Status: Received in OIRA	Previous ICR Reference No: 202304-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Death Gratuity
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 04/17/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	06/30/2026
Responses	7	3
Time Burden (Hours)	2	1
Cost Burden (Dollars)	0	0

Abstract: The National Defense Authorization Act for Fiscal Year 2008, Public Law 110-181, was enacted on January 28, 2008. Section 1105 of P.L. 110-181 amended the Federal Employees' Compensation Act (FECA) creating a new section, 5 U.S.C. § 8102a effective upon enactment. This section establishes a FECA death gratuity benefit of up to $100,000 for eligible beneficiaries of federal employees and Non-Appropriated Fund Instrumentality employees who die from injuries incurred in connection with service with an Armed Force in a contingency operation which also permits agencies to authorize retroactive payment of the death gratuity for employees who died on or after October 7, 2001 in service with an Armed Force in the theater of operations of Operation Enduring Freedom and Operation Iraqi Freedom. It also allows federal employees to vary the order of precedence of beneficiaries or to name alternate beneficiaries and provides that the OWCP Forms CA-40, CA-41, and CA-42 are to be used to designate beneficiaries and initiate the payment process for death gratuity benefits. Form CA-40 is an optional form that requests the information necessary from the employee to accomplish this variance and to name alternate beneficiaries only if the employee wishes to do so. OWCP Form CA-41 provides the means for those named beneficiaries and possible recipients to file claims for those benefits and requests information from such claimants so that OWCP may determine their eligibility for payment. Further, the statute and regulations require agencies to notify OWCP immediately upon the death of a covered employee. OWCP Form CA-42 provides the means to accomplish this notification and requests information necessary to administer any claim for benefits resulting from such a death. Form CA-40 is an optional form that requests the information necessary from the employee to accomplish this variance and to name alternate beneficiaries only if the employee wishes to do so. Form CA-41 provides the means for those named beneficiaries and possible recipients to file claims for those benefits and requests information from such claimants so that OWCP may determine their eligibility for payment. Further, the statute and regulations require agencies to notify OWCP immediately upon the death of a covered employee. OWCP Form CA-42 provides the means to accomplish this notification and requests information necessary to administer any claim for benefits resulting from such a death.

Authorizing Statute(s): PL: Pub.L. 110 - 181 1105 Name of Law: National Defense Authorization Act for Fiscal Year 2008
   US Code: 5 USC 8145 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8102a Name of Law: Amendment to the FECA, Death Gratuity
   PL: Pub.L. 112 - 81 1121 Name of Law: National Defense Authorization Act for Fiscal Year 2012
   US Code: 5 USC 8149 Name of Law: Federal Employees' Compensation Act

Citations for New Statutory Requirements: None

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 4967	02/03/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 20707	04/17/2026
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Death Gratuity Beneficiary Designation	CA-40
Death Gratuity Claim for Survivor Benefits	CA-41
Death Gratuity Official Notice of Employees' Death	CA-42

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	7	3	4
Annual Time Burden (Hours)	2	1	1
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The number of respondents increased from 3 to 7. This increase in respondents was due to more forms received. The number of responses increased from 3 to 7. This increase in responses was due to more forms received. The total number of burden hours increased from 1 hours to 2 hours also due to the increase in respondents. Item 13 costs to respondents remained unchanged at 0.

Annual Cost to Federal Government: $8,214

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Ebony Henry 212 863-0831 henry.ebony@dol.gov

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