(Federal) Form Focus: Evidence in Support of a Dependency Claim

Washington, DC (WorkersCompensation.com) -- Our Simply Research readers learned about a recent update to the CA-1074, which is how OWCP asks for more information in support of a claim for dependency compensation.

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.

Did you know that federal workers' compensation is one of 53 U.S. jurisdictions for which you can find compliance information on Simply Research?

(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.

(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.

Federal claimants can expedite their claim by providing this information before OWCP follows up for more info.

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