Information Collection

Application for Continuation of Death Benefit for Student

IC 13739 under ICR 202309-1240-004 · OMB 1240-0026.

Documents and Forms

Document Name Document Type
Form LS-266 Application for Continuation of Death Benefit for Student Form and Instruction
LS-266 Application for Continuation of Death Benefit LS-266 Continuation of Death Benefit for Student.pdf www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-266.pdf Form and Instruction
LS-266 Application for Continuation of Death Benefit LS-266 Continuation of Death Benefit for Student.pdf www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-266.pdf Form and Instruction
DLHWC Seaportal.pdf DLHWC SEA Portal IC Document
DLHWC Seaportal.pdf DLHWC SEA Portal IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for Continuation of Death Benefit for Student	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 702.121

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	LS-266	Application for Continuation of Death Benefit	LS-266 Continuation of Death Benefit for Student.pdf	https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-266.pdf	Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/OWCP-3	FR Citation: 88 FR 30346

Number of Respondents: 20	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	20	0	20
Annual IC Time Burden (Hours)	10	0	10
Annual IC Cost Burden (Dollars)	7	7	0

Documents for IC

Title	Document	Date Uploaded
DLHWC SEA Portal	DLHWC Seaportal.pdf	09/24/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.