OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Request for Information on Earnings, Dual Benefits, Dependents and Third Part Settlements

ICR 200707-1215-004 · OMB 1215-0151 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form CA-1032 Request for Information on Earnings, Dual Benefits, Dependents and Third Part Settlements Form Modified Available
5 USC ACT Sections 8105, 8106, 8110, 8132, 8148.doc Supplementary Document Uploaded 2007-08-29 Available
20 CFR 10.528 for CA-1032.doc Supplementary Document Uploaded 2007-08-29 Repair queued
NOTE TO REVIEWER - 1215-0151 Aug. 2007.doc Supplementary Document Uploaded 2007-08-29 Available
June 24, 2005 Final FECA Feasability Report - (CA-1032).pdf Supplementary Document Uploaded 2007-08-29 Available
THE PRIVACY ACT OF 1974.doc Supplementary Document Uploaded 2007-08-29 Available
DOL_GOVT-1.doc Supplementary Document Uploaded 2007-08-29 Available
Supporting Statement for 1215-0151 July 23, 2007.doc Supporting Statement A Uploaded 2007-12-12 Available
IC Document Collections
IC IDCollectionTypeStatusForm
13834 Request for Information on Earnings, Dual Benefits, Dependents and Third Part Settlements Form Modified
ICR Details
1215-0151 200707-1215-004
Historical Active 200412-1215-001
DOL/ESA
Request for Information on Earnings, Dual Benefits, Dependents and Third Part Settlements
Extension without change of a currently approved collection   No
Regular
Approved without change 02/06/2008
Retrieve Notice of Action (NOA) 12/21/2007
  Inventory as of this Action Requested Previously Approved
02/28/2011 36 Months From Approved 02/29/2008
50,000 0 50,000
16,667 0 16,667
22,000 0 20,000
The CA-1032 is used to obtain information from claimants receiving compensation for an extended period of time. This information is necessary to ensure that compensation being paid is correct.
US Code: 5 USC 8101-8193 Name of Law: Federal Employees' Compensation Act
  
None
Not associated with rulemaking
  72 FR 49737 08/29/2007
72 FR 72760 12/21/2007
No
  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 50,000 50,000 0 0 0 0
Annual Time Burden (Hours) 16,667 16,667 0 0 0 0
Annual Cost Burden (Dollars) 22,000 20,000 0 0 2,000 0
No
No
$357,625
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Carol Adams 904 357-4747 ext. 74105
  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.
12/21/2007