Information Collection

Statement of Recovery

IC 188783 under ICR 201003-1240-001 · OMB 1240-0001.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0001 can be found here:

Documents and Forms

Document Name Document Type
Form ca-1122 Statement of Recovery Form and Instruction
ca-1122 Statement of Recovery correction 1122 5-4-09[1].doc www/dol.gov/esa/owcp/regs/compliance/ca-1122.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Statement of Recovery	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 10.710 20 CFR 10.707 (e)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	ca-1122	Statement of Recovery	correction 1122 5-4-09[1].doc	http://www/dol.gov/esa/owcp/regs/compliance/ca-1122.pdf	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Central Personnel

Privacy Act System of Records
Title: DOL/GOVT-1 (Office of Worker's Compensation Programs, Federal Employees' Compemsation Act File	FR Citation: 67 FR 16827

Number of Respondents: 300	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	75	75
Annual IC Cost Burden (Dollars)	135	135

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.