Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor

ICR 201011-1240-001 · OMB 1240-0011 · Historical Active

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 1240-0011 can be found here:

Forms and Documents

Document	Type	Status	Availability
Form CM-972 Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor	Form	Modified	Available
1240-0011ss(20101216).doc	Supporting Statement A	Uploaded 2010-12-16	Available
DOL-ESA-6.pdf	Supplementary Document	Uploaded 2007-05-31	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
13877	Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor	Form	Modified

ICR Details

OMB Control No: 1240-0011	ICR Reference No: 201011-1240-001
Status: Historical Active	Previous ICR Reference No: 201003-1240-011
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/21/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/22/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2014	36 Months From Approved	01/31/2011
Responses	285	0	285
Time Burden (Hours)	200	0	200
Cost Burden (Dollars)	0	0	0

Abstract: The purpose of the CM-972 is to collect pertinent data to determine if the representative's services and the amounts charged can be paid under the Black Lung Benefits Act.

Authorizing Statute(s): US Code: 30 USC 901 Name of Law: Black Lung Benefits Act

Citations for New Statutory Requirements: None

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 51487	08/20/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 80539	12/22/2010
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor	CM-972	Application for Approval of a Representative's Fee in a Black Lung Claim Proceeding Conducted by the U.S. Department of Labor

ICR Summary of Burden

	Total Approved	Previously Approved
Annual Number of Responses	285	285
Annual Time Burden (Hours)	200	200
Annual Cost Burden (Dollars)	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

Annual Cost to Federal Government: $4,689

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

Agency Contact: Michael McClaran 202-693-0978 [email protected]

Common Form ICR: No