OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Certification of Funeral Expenses under the Longshore and Harbor Workers' Compensation Act

ICR 202309-1240-005 · OMB 1240-0040 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form LS-265 Certification of Funeral Expenses Form Modified Repair queued
Supporting Statement for 1240-0040 10-2023_MNclean.docx Supporting Statement A Uploaded 2023-10-11 Missing upstream
2023 60-Day FRN_1240-0040.pdf Supplementary Document Uploaded 2023-10-11 Repair queued
PRIVACY ACT SYSTEMS - EFF. 2019.docx Supplementary Document Uploaded 2020-03-25 Missing upstream
20CFR702.121.mht Supplementary Document Uploaded 2011-02-09 Missing upstream
33 USC section 909.doc Supplementary Document Uploaded 2008-01-09 Missing upstream
IC Document Collections
IC IDCollectionTypeStatusForm
13646 Certification of Funeral Expenses Form Modified
ICR Details
1240-0040 202309-1240-005
Received in OIRA 202012-1240-003
DOL/OWCP
Certification of Funeral Expenses under the Longshore and Harbor Workers' Compensation Act
Revision of a currently approved collection   No
Regular 10/17/2023
  Requested Previously Approved
36 Months From Approved 10/31/2023
75 75
19 19
26 1
Form LS-265 is used to report funeral expenses payable under the Longshore and Harbor Workers' Compensation Act.
US Code: 33 USC 913 Name of Law: Longshore and Harbor Workers' Compensation Act
   US Code: 33 USC 939 Name of Law: Longshore and Harbor Workers' Compensation Act
  
None
Not associated with rulemaking
  88 FR 30346 05/11/2023
88 FR 71607 10/17/2023
No
1
IC Title Form No. Form Name
Certification of Funeral Expenses LS-265 Certification of Funeral Expenses
  Total Request 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 75 75 0 0 0 0
Annual Time Burden (Hours) 19 19 0 0 0 0
Annual Cost Burden (Dollars) 26 1 0 25 0 0
No
No
$6,921
No
    No
    No
No
No
No
No
Michelle Massenberg 202 354-9624 [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.
10/17/2023