Information Collection

Representative Fee Request

IC 13744 under ICR 201003-1240-049 · OMB 1240-0049.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0049 can be found here:

Documents and Forms

Document Name Document Type
Form ca-143 Representative Fee Request Form and Instruction
ca-143 attorney fee request ca-143 10-29-09 for 1215-0078.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Representative Fee Request	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 10.700-703 20 CFR 702.132

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	ca-143	attorney fee request	ca-143 10-29-09 for 1215-0078.doc		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: DOL-ESA Notice 15 and DOL/GOVT-1	FR Citation: 58 FR 49599

Number of Respondents: 8,404	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	8,404	-3,936	12,340
Annual IC Time Burden (Hours)	5,419	-2,256	7,675
Annual IC Cost Burden (Dollars)	12,806	-4,595	17,401

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.