U.S. DEPARTMENT OF LABOR 

Office of Workers’ Compensation Programs 

Division of Federal Employees' Compensation

OMB Number: 1240-0017 

Expiration Date: 06/30/2026

CA-40 Designation of a Recipient of the Federal Employees' Compensation Act 

Death Gratuity Payment under 5 U.S.C. § 8102a

A. Identifying Information about the Federal Employee

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

Department or Agency in which presently employed (include 

Bureau, Division, and phone number)

Location (City, State, and ZIP code)

Note: Effective December 31, 2011, employing agencies are required to notify your spouse if you have 

designated all or a portion of the death gratuity to someone other than your spouse. Section 1121 of 

Public Law 112-81.

B. Designating an Alternate Order of Precedence

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 initial, and last name of 

each designee

Address (including ZIP code) of each 

designee

Relationship to you 

(must be parent, 

brother, or sister)

Share to be 

provided to each 

designee

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

language interpretation), accommodations and/or modifications, please contact OWCP. See Instructions 

for additional details.
C. Additional Alternate Beneficiary Designation Provision

In addition to or instead of the above, you may designate another person or persons to receive all or a 

portion 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 provided by statute and described in the 

instructions. Under this provision, you may designate up to 100% 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 or all of your death gratuity. 

First Name, middle initial, and last name 

of each designee

Address (including Zip Code) of each 

designee

Share to be provided to each designee 

(must be in 10% increments)

D. Statement of Federal Employee Completing this Form

I understand that 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 valid designation has been made, the death gratuity will 

be paid according to the order of precedence in as described in the instructions (5 U.S.C. § 8102a). 

I am canceling any and all previous Designations of the death gratuity payment under 5 U.S.C. § 8102a

and am now designating the recipients named above. NOTE: If this notice is completed by the 

employee, it must be sent to the employing agency, signed by the employee's 

supervisor and retained by the employing agency in order to be valid. 

Signature of the Federal Employee. This form is not valid unless the employee signs in this 

box and enters a date in the box to the right. 

Date (mm/dd/yyyy)
E. Signature of the Employing Establishment Official Receiving this Form

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. This form is not valid unless, prior to 

the death of the employee, the official signs in this box and enters a date in the box to 

the right. 

Date (mm/dd/yyyy)

Printed Name, Title, Address and phone and fax numbers of the Employing Establishment Official.

NAME:

TITLE:

ADDRESS:

PHONE NUMBER:

FAX NUMBER:

PRIVACY ACT STATEMENT 

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 amendment to the Federal Employees' 

Compensation Act, 5 U.S.C. § 8102a – Death Gratuity 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 (Executive 

Order 9397, dated November 22, 1943). 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. 

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 number. Public reporting burden for this collection of information is estimated to average 15 minutes 

per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing 

and reviewing the collection of information. The obligation to respond to this collection is voluntary (5. U.S.C. 8102a). Send 

comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this 

burden, to the Office of Workers' Compensation Programs, U.S. Department of Labor, Room S3524, 200 Constitution Avenue, N.W., 

Washington, D.C. 20210, and reference the OMB Control Number 1240-0017. Note: Do not submit the completed claim form to 

this address. 
 The Death Gratuity Payment

CA-40 Instructions Designation of a Recipient of the Death Gratuity 

under 5 U.S.C. § 8102a 

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 beneficiaries 

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 or in accordance 

with the most recent valid alternate beneficiary designations above. Federal employees may use this form to 

designate alternate beneficiaries or to modify the order of precedence of payment of this benefit. 

NOTE: Effective December 31, 2011, employing agencies are required to notify your spouse, if one exists, if you 

designate all or a portion of the death gratuity to someone other than your spouse. 

NOTE TO EMPLOYING AGENCIES: If the federal employee completing this form has a spouse, the agency is 

required effective December 31, 2011 to notify that spouse if the federal employee designates anyone other than 

that spouse to receive all or a portion of the FECA death gratuity pursuant to 5 U.S.C. § 8102a. 

Request for Accommodations or Auxiliary Aids and Services 

If you have a disability, Federal law gives you the right to receive help from the OWCP/DFEC in the form of 

communication assistance, accommodation(s) and modification(s) to aid you in the claims process. For example, we 

will provide you with the copies of documents in alternate formats, communication services such as sign language 

interpretation, or other kinds of adjustments or changes to accommodate your disability. Please contact our office or 

your OWCP claims examiner to ask about this assistance.

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. 

6. If you wish, you may use Section C to designate all or a portion of this benefit to an alternate beneficiary(ies). 

In order for such a designation to be valid, the form must be otherwise valid and you must designate a 

percentage in 10% increments, the alternate must be alive, and the alternate beneficiary must be a person.