OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Survivor's Form for Benefits Under the Black Lung Benefits Act

ICR 201306-1240-004 · OMB 1240-0027 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form CM-912 Survivor's Form for Benefits Under the Black Lung Benefits Act Form Modified Available
DOL Privacy Act Systems ESA-6.pdf Supplementary Document Uploaded 2013-06-25 Available
DOL Privacy Act Systems ESA-30.pdf Supplementary Document Uploaded 2013-06-25 Available
2013 CM-912 1240-0027 Supporting Statement.doc Supporting Statement A Uploaded 2013-09-25 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
13721 Survivor's Form for Benefits Under the Black Lung Benefits Act Form Modified
ICR Details
1240-0027 201306-1240-004
Historical Active 201007-1240-002
DOL/OWCP
Survivor's Form for Benefits Under the Black Lung Benefits Act
Extension without change of a currently approved collection   No
Regular
Approved without change 12/04/2013
Retrieve Notice of Action (NOA) 10/25/2013
  Inventory as of this Action Requested Previously Approved
12/31/2016 36 Months From Approved 12/31/2013
1,100 0 1,750
147 0 233
441 0 681
The CM-912 is used to gather information from a beneficiary's survivor to determine if the survivor is entitled to benefits or the continuation of benefits.
US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
  
None
Not associated with rulemaking
  78 FR 35982 06/14/2013
78 FR 64021 10/25/2013
No
1
IC Title Form No. Form Name
Survivor's Form for Benefits Under the Black Lung Benefits Act CM-912 Survivor's Form For Benefits Under The Black Lung Benefits Act
  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 1,100 1,750 0 0 -650 0
Annual Time Burden (Hours) 147 233 0 0 -86 0
Annual Cost Burden (Dollars) 441 681 0 0 -240 0
No
No
There is a decrease in the approximate number of respondents from 1,750 to 1,100, due to the mortality rate of an aging claimant population. The total number of burden hours has decreased by 650 hours.
$12,552
No
No
No
No
No
Uncollected
Debbie Thurston 202 693-0913 [email protected]
  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.
10/25/2013