CA-1074 

Revised 10-2020

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

Washington, D.C. 20210

OMB NO: 1240-0013 

Expiration Date: 06/30/2026

Sender Address:

Phone:

Date:

Date of Injury: 

Employee:

To Address:

Dear:

Additional information is needed in support of your claim for dependency compensation.

Please supply answers to all questions on the attached questionnaire and complete the 

affidavit which follows.

Further consideration will be given to your claim on receipt of this evidence. This

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

Sincerely,

Name of Signer:

Title:

CC Addresses: 

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-1074 

Revised 10-2020

EVIDENCE REQUIRED IN SUPPORT OF A DEPENDENCY CLAIM

1. State the inclusive dates the deceased was employed during the 12 months

immediately preceding death. Give the names and addresses of his employers

during that period, the rate of pay, and the total amount earned in each job.

2. State whether the deceased was living away from home at any time during the

12-month period before death. If so, give the inclusive dates. Forward any

canceled checks, money order receipts, letters, or other evidence of the fact that

the deceased contributed to your support during that time.

3. If you are now employed, give your Social Security account number, the name of

your employer, your wages, and your occupation. If not now employed, explain

why.

4. State whether your husband (or wife) survives. If he is employed, give his Social

Security account number, employer's name, amount of wages, and occupation.

If not employed, state why.

5. Furnish names and relationship to you of all persons who lived in the same

household with you during the year preceding the death, and the monthly amount

contributed by each toward support of the household.

6. State what support you have received from your surviving children since the

death of the decedent. If they are now living with you and are not contributing to

your support, state why.

7. List all real or personal property owned by you and your husband (wife), including

money on deposit in the bank or invested, and the income from all property and

investments.
3 CA-1074 

Revised 10-2020

8. Submit a copy of the record of birth of the deceased.

9. Submit an affidavit from at least two persons (preferably not related to you or to

the decedent) who have actual knowledge of whether the decedent contributed

to your support during the 12 months before death; whether you were dependent

on these contributions for your livelihood; why this was true and how they (the

affiants) know it to be true.

I certify that the information give in response to his questionnaire is true to the best of my 

knowledge and belief. 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
4 CA-1074 

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 estimated to be 60

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

sources, gathering and maintaining the date 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. 

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, as amended and 

extended (5 U.S.C. 8101, et seq.) (FECA) 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 retention, rehire, 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) 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.

We are authorized to request a taxpayer identification number (TIN) or Social Security 

Number (SSN) under the Debt Collection Improvement Act of 1996, Title 31 U.S.C. 

amended section 7701(c) (1), which mandates us to require regulated entities and 

persons who are doing business with a Federal agency to furnish a TIN or SSN. The 

SSN 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.