Claim for Survivor Benefits - DOL

Division of Federal Employees' Compensation. OMB Number: 1215-0206. Expiration Date: May 31, 2010. Claim for Survivor Benefits Under the Federal Employees’ Compensation Act Section 8102a Death Gratuity (CA-41) Survivor Declaration. I hereby certify that each and every statement made above is true and accurate to the best of my knowledge. ................
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