Information Collection

Request for Intervention, Longshore and Harbor Workers' Compensation Act

IC 237986 under ICR 202012-1240-004 · OMB 1240-0058.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0058 can be found here:

Documents and Forms

Document Name Document Type
Form LS-7 Request for Intervention, Longshore and Harbor Workers' Compensation Act Form and Instruction
LS-4 Attorney Fee Approval Request LS-4 Attorney Fee Approval Request.pdf Form and Instruction
LS-4 Attorney Fee Approval Request LS-4 Attorney Fee Approval Request.pdf Form and Instruction
LS-5 Aplication for Special Fund Relief LS-5 Application for Special Fund Relief.pdf Form and Instruction
LS-5 Aplication for Special Fund Relief LS-5 Application for Special Fund Relief.pdf Form and Instruction
LS-7 Request for Intervention LS-7 Intervention Request.pdf Form and Instruction
LS-7 Request for Intervention LS-7 Intervention Request.pdf Form and Instruction
LS-8 Settlement Approval Request Section 8(i) LS-8 Settlement Approval Request 8(i).pdf Form and Instruction
LS-8 Settlement Approval Request Section 8(i) LS-8 Settlement Approval Request 8(i).pdf Form and Instruction
LS-9 Stipulation Approval Request LS-9 Stipulation Approval Request.pdf Form and Instruction
LS-9 Stipulation Approval Request LS-9 Stipulation Approval Request.pdf Form and Instruction
LS-6 LS-6 Commutation Application LS-6 Commutation Application.pdf Form and Instruction
LS-6 LS-6 Commutation Application LS-6 Commutation Application.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for Intervention, Longshore and Harbor Workers' Compensation Act	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 702.301 20 CFR 702.311 20 CFR 702.315 20 CFR 702.134 20 CFR 702.312 20 CFR 702.142 20 CFR 702.102 20 CFR 702.321 20 CFR 702.242

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	LS-4	Attorney Fee Approval Request	LS-4 Attorney Fee Approval Request.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	LS-5	Aplication for Special Fund Relief	LS-5 Application for Special Fund Relief.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	LS-7	Request for Intervention	LS-7 Intervention Request.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	LS-8	Settlement Approval Request Section 8(i)	LS-8 Settlement Approval Request 8(i).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	LS-9	Stipulation Approval Request	LS-9 Stipulation Approval Request.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	LS-6	LS-6 Commutation Application	LS-6 Commutation Application.pdf	Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/OWCP-3, DOL/OWCP-4	FR Citation: 81 FR 25765

Number of Respondents: 12,414	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 70 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	12,414	0	12,414
Annual IC Time Burden (Hours)	3,189	-2	3,191
Annual IC Cost Burden (Dollars)	343	343	0

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.