33. Account number: 34. Routing or transit number:

U.S. Department of Labor Claim for Compensation by Parents, Office of Workers' Compensation Programs Brothers, Sisters, Grandparents, or

Grandchildren

OMB No. 1240-0013

Expires: 06/30/2026

1. Name of deceased employee 2. Date of Birth 3. Date of Injury 4. Date of Death 5. Social Security Number

(Mo., day, year) (Mo., day, year) (Mo., day, year)

6. Name and address of employing agency (Include ZIP Code) 7. Nature of injury which caused death

Dependent's birth date

(Mo., day, year)

8. Name of dependent (Last, first, middle) 9. Dependent's address (Include ZIP Code)

Extent of dependency on

employee

Dependent's relationship to

employee

Dependent's Social

Security Number

11. Dependent's Occupation

Total Partial

Did employee live with 17. Total amount employee paid 18. If no fixed amount was paid

dependent during the 12

months immediately prior

to death?

for room and board, what is

the fair value of such room

and board?

dependent in money or service

for room and board in addition to

amount shown in 15.

Yes No $ $ Per $ Per

If ''Yes'', Complete 17 & 18.

If dependent was employed during 12 month period prior to

employee's death, give:

Show dependent's income from all sources other than employment

during 12 month period prior to employee's death:

20.

Type of work performed:

Period of employment:

Monthly pay rate:

Name and address of employer:

Investments $

Pensions

Persons other than employee

Other

Total $

Information about spouse (Items 21 through 25)

Total income from all sources for 12 months prior to 

employee's death.

21. Birth Date (Mo., day, year) 22. Occupation 23. Monthly pay rate

$ $

25. List all property owned by dependent and spouse (omit clothing, furniture, personal items).

If an application has been made for Veterans Administration (VA)

benefits because of employee's death, give: If an application has been made for U.S. Civil Service Annuity or any

other Federal Retirement or Disability Law because of employee's

death, give: Service number: VA Claim number:

Retirement System: CSRS FERS SSA Other Address of VA office where claim is filed:

a. Claim number for each claim:

b. If a claim has been made against a third party because of employee's death, give:

a. Amount of recovery: $ Date each benefit began: b. Name and address of third party:

a. Amount of each benefit paid per month: $ b.

I certify that the information provided above is true and accurate to the best of my knowledge and belief. 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 civil or administrative remedies as well as criminal prosecution and may, under appropriate criminal provisions, be punished by 

a fine or imprisonment, or both. In addition, a state or federal criminal conviction for FECA fraud will result in termination of all current and future FECA benefits.

35. Signature of person filing claim 36. Address (Include ZIP Code) 37. Date

(Mo., day, year)

Form CA-5b (Rev. 10-2020)

10.

14.

15.

12. 13.

16.

19.

24.

26. 27.

Total amount employee

contributed to dependent's

support during 12 months

immediately prior to death.

28.

Description Date Acquired Value

29. Total burial expense Amount of burial expense paid

or payable by VA Name and address of party (other than VA) whose funds were used to pay burial expense

and amount paid:

30. 31.

$ $ $

32. Name of Financial Institution for Depositing Benefits: Checking Savings

(Last, first, middle)

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.
Attending Physician's Report

1. Name of deceased employee (Last, first, middle) 2. Date of death (Mo., day, year)

3. What history of injury or employment related disease was given to you? 4. If treated for disease, give diagnosis.

6. Show dates on which treatment

was given.

5. If death was not instantaneous, describe the treatment you provided.

7. What was the direct cause of death?

8. What were the contributory causes of death, if any?

In your opinion, was the death of the employee due to the injury or employment related disease as reported in item 3 above?

Give the medical reasons for your opinion, unless causal relationship is obvious. Yes No

Was a biopsy or an autopsy performed?

Arrange for a copy of the report to be submitted. Yes No

11. Name, specialty, and address of physician (Please type - include ZIP Code)

I certify that the statements in response to the questions asked above are true, complete, and correct to the best of my knowledge. Further, I 

understand that any false or misleading statements or any misrepresentation or concealment of material fact which is knowingly made may 

subject me to criminal prosecution.

12. Signature 13. Date signed (Mo., day, year)

9.

10.

Form CA-5b PAGE 2 (Rev.10-2020)
INSTRUCTIONS FOR COMPLETING FORM CA-5b, CLAIM FOR COMPENSATION

BY PARENTS, BROTHERS, SISTERS, GRANDPARENTS OR GRANDCHILDREN

Who Should This claim form should be completed and filed by the deceased employee's parents,

grandparents or representative (custodian or guardian) of minor brothers, sisters or

grandchildren. A separate form is required for each person claiming benefits.

File Claim

Claim must be filed within three years following date of death, unless the

decedent's immediate superior had actual knowledge of an on-the-job injury or

death within 30 days; or written notice of the injury or death was given within 30

days. The timely filing of a disability claim will satisfy the time requirements for a

death claim based on the same injury.

When Should

Claim Be Filed

The birth certificate of the deceased employee; also a death certificate if not previously submitted; birth certificates for minor brothers, sisters and grandchildren. If

claim is made on behalf of a grandparent, birth certificate of decedent's mother or

father, as appropriate. If claim is made on behalf of a grandchild, birth certificate of

decedent's son or daughter as appropriate. Copies of certificates or documents are

acceptable only if they are certified by the person having official custody of such

records. They should then be attached to the claim form when it is filed.

What Documents

Are Required

How to All items on the claim form should be completed. If an item is not applicable, indicate by

showing "NA". Note that the claim form requests information about several categories of

persons, i.e., items 1-7 make inquiry about the decedent; 8-20 the dependent; 21-25 the

dependent's spouse, if married at the time of employee's death. The attending

physician's report on the reverse of the form must also be completed before the form is

Complete Claim

 is submitted to the OWCP.

Funeral/Burial Submit original itemized funeral and burial bills. If paid, so indicate and give name and

Allowance address of person making payment. if an Administrator or Executor has been

appointed, give such person's name and address and attach a copy of the appointment

document.

See the following page for a definition of dependents and a description of benefits.

Form CA-5b PAGE 3 (Rev. 10-2020)

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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/or modification(s) to aid you in the FECA 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.
DEATH BENEFITS FOR PARENTS, BROTHERS, SISTERS, GRANDPARENTS

AND GRANDCHILDREN UNDER THE FEDERAL EMPLOYEES' COMPENSATION ACT (FECA)

Benefits are payable on behalf of partially or totally dependent parents, brothers, sisters,

grandparents and grandchildren.

Eligible

Dependents

Period Of Parents and grandparents: Payments continue until death, remarriage or termination of

Entitlement dependency.

Minor brothers, sisters and grandchildren: Payments continue until death, marriage or

attainment of 18 years of age. Payments may continue beyond 18 if the child is mentally or

physically incapable of self-support or is a "full-time" student. Student benefits terminate on:

marriage, completion of 4 years of education beyond high school level, or at age 23,

whichever occurs first.

For parent - 25% of the employee's monthly pay, if one is wholly dependent and the other is

not dependent at all. If both are wholly dependent - 20% each. A proportionate amount is

paid if either or both are partially dependent.

Compensation

Rates

Brothers, sisters, grandparents, and grandchildren - 20% if only one is wholly dependent. If

more than one is wholly dependent - 30% shared equally. If one or more is partially dependent

- 10% shared equally if more than one.

If the employee was covered under the Federal Employees's Retirement System (FERS), 5

USC 811 (d)(2) requires that Social Security benefits payable to beneficiaries, which are

attributable to the deceased employee's Federal Service, are deducted from the beneficiary's

compensation entitlement.

Payment Monthly payments for all beneficiaries cannot exceed 75% of the employee's monthly

salary or 75% of the top step of GS-15 of the General Schedule. The surviving spouse

and children have first priority. Other eligible dependents may receive payment only if

the surviving spouse and children's percentages are less than 75%.

Priorities

Funeral/Burial Funeral and burial expense up to a maximum of $800 may be paid. Amount paid by

the VA will be deducted. If death occurs away from the employee's duty station,

transportation costs may be paid to return the deceased employee to his home or

last place of residence. In addition to any funeral or burial expenses, a sum of $200

may be paid for reimbursement of the costs of termination of the decedent's status

as an employee of the United States.

Allowance

If the employee's death was caused by a person or party other than the Federal

Government, a ''third party action'' or lawsuit may be indicated. In such instances the

Department of Labor will provide further instructions.

Third Party

Action

The Department of Treasury requires all Federal payments be made by electronic funds transfer (EFT), 

also called Direct Deposit. You may submit a completed SF-1199A, Direct Deposit Sign Up, or complete 

the information in items 32 through 34 of this form. If you do not have a bank account, you may be 

required to receive your payment through Direct Express Debit MasterCard. To request information on the 

Direct Express Debit MasterCard, go to www.usdirectexpress.com or call 1-800-333-1795. If directed to 

enroll in the Program, you may contact for the Department of Treasury at 1-888-224-2950 to address any 

questions or concerns you may have, as well as apply for a waiver from the process. NOTE: payments to 

residents of foreign countries are exempt from the Treasury requirement.

•

Information

Direct Deposit

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Form CA-5b PAGE 4 (Rev. 10-2020)

Benefits

Social Security
Privacy Act Notice

Public Burden Statement

Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.

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.

Public reporting burden for this collection of information is estimated to average 90 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 obligation 

to respond to this collection is required to obtain or retain a benefit (5 U.S.C. 8101 et seq.). Send comments regarding this 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 S-3229, 200 Constitution Avenue, N.W., Washington, D.C. 20210, and reference the OMB Control Number 1240-0013. 

Form CA-5b PAGE 5 (Rev. 10-2020)