Department of Veterans Affairs

Washington, DC

Worklife and Benefits Service (058)

FLYER

Benefits 08-29

June 3, 2008

### TO: Chief, HRMS

**SUBJ: Department of Labor (DOL) Death Gratuity Payment under Section
1105 of**

**Public Law 110-181**

The purpose of this Flyer is to provide Human Resources (HR) offices
with information regarding DOL's new Death Gratuity Payment as
authorized under Section 1105 of Public Law 110-181. This death gratuity
was placed within the Federal Employees' Compensation Act (FECA) and
will be administered by DOL's Office of Worker's Compensation Program
(OWCP).

This new benefit creates a death gratuity for federal employees (and
employees of non-appropriated fund instrumentalities) by authorizing the
United States to pay **up to \$100,000 to the survivors of "an employee
who dies of injuries incurred in connection with the employee's service
with an Armed Force in a contingency operation".**

This provision became effective on January 28, 2008 and OWCP is
currently drafting regulations implementing the amendment. The statute
provides Federal employees in service with an Armed Force in a
contingency operation to designate the distribution of the new death
gratuity, should one be unfortunately payable to their loved ones. The
beneficiary stipulations are unique to this new provision and no
existing DOL rules or guidelines cover these circumstances. HR offices
can find further explanation and guidance regarding this new provision
and print off copies of the new beneficiary form at the following DOL
Web site: <http://www.dol.gov/esa/regs/compliance/OWCP/fecacont.htm>.

**DISCLAIMER: This new death gratuity provision applies to Department of
Veterans Affairs (VA) employees who are in service with an Armed Force
in a contingency operation while remaining in their civilian employment
capacity. This does not include VA employees who have been called up to
active duty in the Reserves, National Guard or an Active Armed Forces
component.**

**IMMEDIATE ACTION NECESSARY:** The Worklife and Benefits Service is
providing an "Employee Handout," Designation of a Recipient of Death
Gratuity Payment (beneficiary form), and related beneficiary form
instructions on the following pages of this Flyer. **As soon as
possible, HR managers need to ensure that this Employee Handout, along
with a copy of the beneficiary form, is provided to your employees who
are currently in service with an Armed Force in a contingency operation.
These employees must be given the opportunity to designate one or more
beneficiaries of a death gratuity payable under this provision. You may
wish to mail copies of the Employee Handout, beneficiary form and the
beneficiary form instructions to these individuals' last known home
address and ask that their family members forward this information to
them as soon as possible.**

**Additionally, any time a Federal employee is in service with an Armed
Force in a contingency operation, he or she must be informed of this
death gratuity and be given the opportunity to designate a beneficiary
on the appropriate form. From this point on, HR offices are to provide a
hard copy of the Employee Handout, the beneficiary form, and the
beneficiary form instructions to all employees who meet this criterion
as part of the counseling and clearance process.**

**[HR offices are to file completed beneficiary forms or statements on
the right hand side of the Official Personnel Folder (OPF). HR offices
and/or the OWCP specialist will need to fill in their contact
information in the last paragraph on the Employee Handout before
distributing to employees]{.underline}.**

**Please share this Flyer with your station's OWCP specialist. HR
managers are to ensure that the OWCP specialist is notified immediately
should an employee die under these provisions.**

Questions regarding this Flyer should be directed to David L. Hull,
Department of Veterans Affairs, Workers' Compensation Program Manager,
Office of Occupational Safety and Health, at (202) 461-5022. In
addition, OWCP specialists are required to report the deaths of such
employees immediately to David Hull at the number listed above.

**Office of Human Resources and Administration**

**Office of Human Resources Management**

**ATTENTION: THE NEW DEATH GRATUITY PROVISION APPLIES TO FEDERAL
CIVILIAN EMPLOYEES WHO ARE CURRENTLY IN SERVICE WITH AN ARMED FORCE IN A
CONTINGENCY OPERATION AND TO THOSE WHO WILL BE IN SERVICE WITH AN ARMED
FORCE IN A CONTINGENCY OPERATION. THIS DOES NOT APPLY TO EMPLOYEES WHO
HAVE BEEN CALLED UP TO ACTIVE DUTY.**

The Federal Employees' Compensation Act (FECA) was recently amended with
the addition of section 8102a (5 U.S.C. § 8102a). (See section 1105 of
the National Defense Authorization Act for FY 2008, Public Law 110-181.)
This new provision creates a death gratuity for federal employees (and
employees of nonappropriated fund instrumentalities) and authorizes the
United States to pay up to \$100,000 to the survivors of "an employee
who dies of injuries incurred in connection with the employee's service
with an Armed Force in a contingency operation."  Unlike other death
gratuities, this death gratuity was placed within FECA and, for that
reason, will be administered by the Department of Labor's Office of
Workers' Compensation Programs (OWCP) as part of the FECA program.

This provision became effective on January 28, 2008, and OWCP is
currently drafting regulations implementing the amendment. This one-time
death gratuity is to be disbursed to the survivors of the employee in a
specific order of precedence set forth in the law. **The law also
provides you, the employee, the opportunity to change the order of
precedence in regard to certain survivors as well as designate up to 50
percent of the benefit to any person.**

A new Death Gratuity Payment beneficiary form has been created and is a
part of this Handout. You may use this form to designate the
distribution of the death gratuity, should one be payable. The
instructions accompanying the form explain the order of precedence that
governs awarding the death gratuity and the optional designations that
an employee can make. **[No designation is necessary if you wish any
death gratuity to be distributed in accordance with the order of
precedence]{.underline}.**

If you wish to designate one or more beneficiaries the death gratuity
payable under this provision, you should complete and sign a copy of
this form, retain a copy, and give the original to your Human Resources
(HR) office to be maintained by them in case it should be needed at any
time in the future.

You should utilize the official beneficiary form to avoid potential
difficulties in discerning your intentions. However, DOL recognizes that
there will be circumstances where this is not possible. In the event
that the attached form is not utilized to make a desired designation,
OWCP will recognize any document specifying the beneficiary designation
that you desire to make if **it is both signed and dated by you and
signed and dated by a VA official prior to your death**. Employees not
using the form should clearly specify any designation they wish to make.

Questions regarding this Handout should be directed to (insert local HR
office and/or OWCP specialist contact information). You may find
additional information at the following DOL Web site:
<http://www.dol.gov/esa/regs/compliance/OWCP/fecacont.htm>.

**Designation of a Recipient of the Death Gratuity Payment under**

**Section 1105 of Public Law 110-181**

  ----------------------- ----------------------- -----------------------
  Name (Last, First,      Date of Birth           Social Security Number
  Middle)                                         

  Department or Agency in                         Location (City, State,
  which presently                                 and ZIP code)
  employed (include                               
  Bureau, Division, and                           
  phone number)                                   
  ----------------------- ----------------------- -----------------------

If you have no surviving spouse or child eligible to receive the death
gratuity, and you wish to designate

any one or more of your parents or brothers or sisters to receive
specific shares of the gratuity, please fill

in the required boxes below. If you designate more than one individual
and do not indicate a share for

each individual, the death gratuity will be paid to those individuals in
equal shares. **An individual**

**designated below must be living at the time of payment to receive any
or all of your death gratuity**.

  ------------------------ ------------------------ -------------- ----------
  First Name, middle       Address (including ZIP   Relationship   Share to
  initial, and last name   code) of each designee   to you (must   be
  of each designee                                  be parent,     provided
                                                    brother, or    to each
                                                    sister)        designee

                                                                   

                                                                   

                                                                   

                                                                   
  ------------------------ ------------------------ -------------- ----------

I

In addition to or instead of the above, you may designate any person or
persons to receive up to 50% of

your death gratuity. If you do not designate anyone in this section,
100% of the death gratuity will be

disbursed according to the order of precedence described in the
instructions. Under this provision, you

may designate a maximum of 50% of the death gratuity in 10% increments.
If you utilize this designation

provision, the undesignated portion of the death gratuity will be
disbursed as specified in the order of

precedence. **An individual designated below must be living at the time
of payment to receive any**

**of your death gratuity.**

  ----------------------------- ----------------------------- -------------
  First Name, middle initial,   Address (including ZIP code)  Share to be
  and last name of each         of each designee              provided to
  designee                                                    each designee
                                                              (must be in
                                                              10%
                                                              increments)

                                                              

                                                              

                                                              

                                                              

                                                              
  ----------------------------- ----------------------------- -------------

I understand that if this Designation is not valid unless delivered to
an official of the employing

Establishment prior to the death of the employee and that it will stay
in effect unless it is cancelled.

I understand that if this Designation is invalid for any reason, the
death gratuity will be paid according to

the next most recent valid designation. In the event no designation has
been made, the death gratuity will

pay according to the order of precedence in section 1105 of Public Law
110-181 as described in the

instructions.

I am canceling any and all previous Designations of the death gratuity
payment under Public Law 110-

181, section 1105, and am now designating the recipients named above.

  ----------------------------------------------------- -----------------
  Signature of the Federal Employee. **This form is not Date (mm/dd/yyyy)
  valid unless the employee signs in this box and       
  enters a date in the box to the right.**              

  ----------------------------------------------------- -----------------

I have received this form from the federal employee who has signed
above. To the best of my knowledge

and belief, the employee has filled out this form completely in
accordance with the instructions on the form.

+-----------------------------------------------------+----------------+
| Signature of the Employing Establishment Official.  | Date           |
| **This form is not valid unless, [prior to the      | (mm/dd/yyyy)   |
| death of the employee]{.underline}, the official    |                |
| signs in this box and enters a date in the box to   |                |
| the right.**                                        |                |
+-----------------------------------------------------+----------------+
| Printed Name, Title, Address and phone and fax      |                |
| numbers of the Employing Establishment Official.    |                |
|                                                     |                |
| NAME:                                               |                |
|                                                     |                |
| TITLE:                                              |                |
|                                                     |                |
| ADDRESS:                                            |                |
|                                                     |                |
| PHONE NUMBER:                                       |                |
|                                                     |                |
| FAX NUMBER:                                         |                |
+-----------------------------------------------------+----------------+

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a),
you are hereby notified that: (1) The Federal Employees'

Compensation Act (FECA), as amended and extended (5 U.S.C. 8101, et
seq.) including the Death Gratuity in section 1105 of

Public Law 110-181 is administered by the Office of Workers\'
Compensation Programs of the U.S. Department of Labor, which

receives and maintains personal information on claimants and their
immediate families. (2) Information which the Office has will be

used to determine eligibility for and the amount of benefits payable
under the FECA, and may be verified through computer matches

or other appropriate means. (3) Information may be given to the Federal
agency which employed the claimant at the time of injury in

order to verify statements made, answer questions concerning the status
of the claim, verify billing, and to consider issues relating

to entitlement to benefits or other relevant matters. (4) Information
may be given to Federal, state and local agencies for law

enforcement purposes, to obtain information relevant to a decision under
the FECA, to determine whether benefits are being paid

properly, including whether prohibited dual payments are being made,
and, where appropriate, to pursue salary/administrative offset

and debt collection actions required or permitted by the FECA and/or the
Debt Collection Act. (5) Disclosure of the claimant\'s social

security number (SSN) or tax identifying number (TIN) on this form is
mandatory. The SSN (and/or TIN), and other information

maintained by the Office, may be used for identification, to support
debt collection efforts carried on by the Federal government,

and for other purposes required or authorized by law. (6) Failure to
disclose all requested information may delay the processing of the

claim or the payment of benefits, or may result in an unfavorable
decision or reduced level of benefits.

**Note: This notice applies to all forms requesting information that you
might receive from the Office in connection with**

**the processing and adjudication of the claim you filed under the
FECA.**

**Designation of a Recipient of the Death Gratuity Payment under**

**Section 1105 of Public Law 110-181**

**INSTRUCTIONS**

If a federal civilian employee or an employee of a nonappropriated fund
instrumentality dies of injuries incurred in connection with his or her
service with an Armed Force in a contingency operation, his or her
eligible survivors may receive a death gratuity payment of up to
\$100,000. The gratuity is a one-time payment disbursed to the highest
ranked survivor or survivors of the employee according to the order of
precedence below.

**You do not need to fill out this form if you are satisfied that 100%
of the gratuity will be paid entirely to the survivor highest on the
list below:**

1.  Your surviving spouse.

2.  If you do not have a surviving spouse, your death gratuity will be
    paid to your children, in equal shares. Your children include any
    adopted children, stepchildren who are part of your household at the
    time of death, and any illegitimate children, subject to the
    following limitation. An illegitimate child of a male decedent only
    qualifies as an eligible survivor if the child:

    -   has been acknowledged in writing signed by the decedent;

    -   has been judicially determined, before the decedent\'s death, to
        be his child;

    -   has been otherwise proved, by evidence satisfactory to the
        employing agency, to be a child of the decedent; or

    -   is a child to whose support the decedent had been judicially
        ordered to contribute.

3.  If you have no surviving spouse or eligible child, you can choose to
    divide your death gratuity among your parents or brothers or
    sisters, as you designate in section B of the form.

    -   The term "parents" includes adoptive parents and persons who
        stood in loco parentis to the decedent for not less than one
        year before the decedent became an employee covered by this
        provision, but the term is limited to one father or mother or
        their counterparts.

    -   "Brothers" and "sisters" include half-brothers and half-sisters,
        and brothers and sisters through adoption.

4.  If you have no surviving spouse or eligible child and do not
    designate anyone in section B of the form, your death gratuity will
    be paid to your living parent or parents, in equal shares.

5.  If you have no surviving spouse, eligible child, or living parent
    and do not designate anyone in section B of the form, your death
    gratuity will be paid to your brothers and sisters, in equal shares.