CA-1031 

Revised 10-2020

U. S. Department of Labor Office of Workers’ Compensation Programs

Washington, D.C. 20210

File Number:

OMB NO: 1240-0013 

Expiration Date: 06/30/2026

Sender Address:

Phone:

Date:

Date of Injury: 

Employee:

Dep(s):

To Address:

Dear: 

To help us reach a decision regarding a claim for compensation filed by

_________________, please furnish the information requested below. This information 

is required to obtain or retain a benefit (5 U.S.C. 8101 et seq.). 

1. State your relationship to employee (that is, wife, husband, natural parent or guardian

of dependent(s) named above, or parent of employee).

______________________________________________________________________

2. State the amount of money that employee regularly contributes to your support or to

the support of the dependent(s) named above. State how often the contributions are

made – weekly, monthly, etc. If contributions are not made at regular intervals or in the

form of money, please explain.

______________________________________________________________________

______________________________________________________________________ 

______________________________________________________________________ 

______________________________________________________________________ 

If you have a disability and are in need of communication assistance (such as alternate 

formats or sign language interpretation), accommodation(s) and/or modification(s), 

please contact OWCP. 
2 CA-1031 

Revised 10-2020

3. Approximate date such contributions were first made:

______________________________________________________________________

4. If you are natural parent or legal guardian of the dependent(s) named above, give the

age and relationships to the employee of each dependent.

______________________________________________________________________

______________________________________________________________________

5. If you are a parent of the employee, state the source and amount of all your other

income. If none, so state.

______________________________________________________________________

______________________________________________________________________

I certify that each and every statement made above is true to the best of my knowledge. 

I further understand that any person who knowingly makes any false statement, 

misrepresentation, concealment of fact, or any other act of fraud to obtain compensation 

as provided by the FECA or who knowingly accepts compensation to which that person 

is not entitled is subject to felony criminal prosecution and may, under appropriate 

criminal provisions, be punished by a fine or imprisonment or both.

__________________________________________ ____________

Signature Date

Sincerely,

Name of Signer:

Title:

CC Addresses:
3 CA-1031 

Revised 10-2020

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond 

to a collection of information unless such collection displays a valid OMB control 

number. Public reporting burden for this collection of information is estimated to average 

20 minutes per response, including time for reviewing instructions, searching existing 

data sources, gathering and maintaining the data needed, and completing and reviewing 

the collection of information. The authority for requesting this information is 5 U.S.C. 

8101 et seq. The information will be used to determine entitlement to benefits. 

Furnishing the requested information is required for the claimant to obtain or retain a 

benefit. Send comments regarding the burden estimate or any aspect of this collection 

of information, including suggestions for reducing this burden, to the Office of Workers' 

Compensation Programs, Department of Labor, Room S-3229, 200 Constitution Avenue, 

NW, Washington, DC 20210, and reference the OMB Control Number 1240-0013. Note: 

please do not send the completed form to this office; rather, send it to the address 

shown on the letterhead.