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Federal forms, ICRs, and supporting documents

Information Collection Request

MAINTENANCE OF RECEIPTS FOR BENEFITS PAID BY A COAL MINE OPERATOR (RECORD KEEPING REQUIREMENT)

ICR 198310-1215-004 · OMB 1215-0124 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
122223 MAINTENANCE OF RECEIPTS FOR BENEFITS PAID BY A COAL MINE OPERATOR (RECORD KEEPING REQUIREMENT) Form Migrated
ICR Details
1215-0124 198310-1215-004
Historical Active 198112-1215-001
DOL/ESA
MAINTENANCE OF RECEIPTS FOR BENEFITS PAID BY A COAL MINE OPERATOR (RECORD KEEPING REQUIREMENT)
Revision of a currently approved collection   No
Regular
Approved without change 11/02/1983
Retrieve Notice of Action (NOA) 10/28/1983
  Inventory as of this Action Requested Previously Approved
11/30/1986 11/30/1986 12/31/1983
150 0 150
1 0 1
0 0 0
CFR 725.531 REQUIRES SELF-INSURED OPERATORS OR INSURANCE CARRIERS WHO MAKE BENEFIT PAYMENTS TO BLACK LUNG BENEFICIARIES TO MAINTAIN RECEIPTS FOR THOSE PAYMENTS FOR FIVE YEARS. CANCELLED CHECKS WILL SUFFICE.
None
None
No
1
IC Title Form No. Form Name
MAINTENANCE OF RECEIPTS FOR BENEFITS PAID BY A COAL MINE OPERATOR (RECORD KEEPING REQUIREMENT) CM-200
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 150 150 0 0 0 0
Annual Time Burden (Hours) 1 1 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
  No
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.
10/28/1983