MINER'S CLAIM FOR BENEFITS UNDER THE BLACK LUNG BENEFITS ACT, HISTORY OF COAL MINE EMPLOYMENT, AND DRUG, RESPIRATORY THERAPY, OXYGEN AND MEDICAL EQUIPMENT REIMBURSEMENT FORM
ICR 198305-1215-001 · OMB 1215-0052 · Historical Active
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 1215-0052 can be found here:
MINER'S CLAIM FOR BENEFITS UNDER THE BLACK LUNG BENEFITS ACT, HISTORY OF COAL MINE EMPLOYMENT, AND DRUG, RESPIRATORY THERAPY, OXYGEN AND MEDICAL EQUIPMENT REIMBURSEMENT FORM
THE MINE'S CLAIM FOR BENEFITS UNDER THE BLACK LUNG BENEFITS ACT MUST B REVISED TO OBTAIN EARNINGS INFORMATION FROM MINER FILING A CLAIM AFTER DECEMBER 31, 1981, AS REQUIRED BY THE 1981 AMENDMENTS TO THE ACT SO BENEFITS MAY BE ADJUSTED DUE TO EXCESS EARNINGS.
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
MINER'S CLAIM FOR BENEFITS UNDER THE BLACK LUNG BENEFITS ACT, HISTORY OF COAL MINE EMPLOYMENT, AND DRUG, RESPIRATORY THERAPY, OXYGEN AND MEDICAL EQUIPMENT REIMBURSEMENT FORM