Form CA-40 Instructions

Form CA-40 "Designation of a Recipient of the Federal Employees' Compensation Act Death Gratuity Payment Under 5 U.S.C.  8102a"
Section A. Identifying Information about the Federal Employee:  Must be completely filled out with the full name, date of birth, Social Security Number, and EA contact information.

Section B. Designating an Order of Precedence: If the employee does not have a surviving spouse or child eligible to receive the death gratuity,  and he/she wishes to designate his/her parent(s), brother(s) and/or sister(s) to receive a percentage of the gratuity,  he/she should complete this section with the individual(s) full name, complete address, their relationship to the employee, and the share (%) of the gratuity to be provided to each individual.

Section C.  Additional Alternate Beneficiary Designation Provision: In addition to or instead of the above, the employee may designate another person or persons to receive all or a portion of the death gratuity (in 10% increments).

Section D.  Statement of Federal Employee Completing this Form: The employee must sign and date the form.  NOTE: In order to be valid, once the form is signed by the employee - it must be sent to the EA, signed by the employee's supervisor and retained by the EA.

Section E. Signature of the Employing Establishment Official Receiving this Form:  This form is not valid unless, prior to the death of the employee, the EA official signs and dates the form.  The complete printed name, title, address, telephone and fax of the Employing Establishment Official must be provided.