OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

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

ICR 201309-1240-002 · OMB 1240-0011 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
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 Repair queued
DOL Privacy Act Systems ESA-6.pdf Supplementary Document Uploaded 2013-09-11 Repair queued
SUPPORTING STATEMENT 1240-0011 (2014).doc Supporting Statement A Uploaded 2014-01-30 Available
IC Document Collections
IC IDCollectionTypeStatusForm
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
1240-0011 201309-1240-002
Historical Active 201011-1240-001
DOL/OWCP
Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor
Revision of a currently approved collection   No
Regular
Approved without change 03/25/2014
Retrieve Notice of Action (NOA) 01/30/2014
  Inventory as of this Action Requested Previously Approved
03/31/2017 36 Months From Approved 03/31/2014
338 0 285
237 0 200
0 0 0
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.
US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
  
None
Not associated with rulemaking
  78 FR 55761 09/11/2013
79 FR 4975 01/30/2014
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 338 285 0 0 53 0
Annual Time Burden (Hours) 237 200 0 0 37 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
Due to the passage of the Byrd Amendment, approved claims increased and more attorney fee applications were received. The changes are not expected to affect the public burden. We also added the Privacy Act and Accommodation Statement on the form.
$5,563
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.
01/30/2014