Information Collection

EE 5A - Supplemental Employment Evidence

IC 251535 under ICR 202603-1240-001 · OMB 1240-0002.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	EE 5A - Supplemental Employment Evidence	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 30.112

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/OWCP-11	FR Citation: 81 FR 25868

Number of Respondents: 163	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	163	163
Annual IC Time Burden (Hours)	82	82
Annual IC Cost Burden (Dollars)	55	55

Documents for IC

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

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