OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

NOTICE TO BENEFICIARY (RO MONTHLY) NOTICE TO BENEFICIARY (RO MBO) NOTICE TO BENEFICIARY (TF MBO)

ICR 199504-1215-001 · OMB 1215-0179 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
122381 NOTICE TO BENEFICIARY (RO MONTHLY) NOTICE TO BENEFICIARY (RO MBO) NOTICE TO BENEFICIARY (TF MBO) Form Migrated
ICR Details
1215-0179 199504-1215-001
Historical Active 199211-1215-003
DOL/ESA
NOTICE TO BENEFICIARY (RO MONTHLY) NOTICE TO BENEFICIARY (RO MBO) NOTICE TO BENEFICIARY (TF MBO)
Revision of a currently approved collection   No
Regular
Approved without change 06/06/1995
Retrieve Notice of Action (NOA) 04/12/1995
Approved as amended by DOL's 6/5/95 memorandum to OMB. DOL has indicated that the burden for information collected through the CM999a is accounted for under OMB #1215-0052. Accordingly, DOL shall add a reference to that form (CM-911) in the text of the CM-999a.
  Inventory as of this Action Requested Previously Approved
06/30/1995 06/30/1995 01/31/1996
0 0 0
0 0 2,509
0 0 0
TO HELP DETERMINE CONTINUING ELIGIBILITY OF PRIMARY BENEFICARIES RECEIVING MONTHLY MONETARY BENEFITS AND/OR MEDICAL BENEFITS FROM A RESPONSIBLE COAL MINE OPERATOR. TO UPDATE AND VERIFY ON AN ANNUAL BASIS FACTORS THAT AFFECT A BENEFICIARY'S ENTITLEMENT OF BENEFITS.
None
None
No
1
IC Title Form No. Form Name
NOTICE TO BENEFICIARY (RO MONTHLY) NOTICE TO BENEFICIARY (RO MBO) NOTICE TO BENEFICIARY (TF MBO) CM-999A, CM-999B, CM-999C
  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 0 0 0 0 0 0
Annual Time Burden (Hours) 0 2,509 0 -2,509 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
$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.
04/12/1995