ELIGIBILITY DATA FORM

ICR 197504-1210-003

OMB: 1210-0010

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
168314 Migrated
ICR Details
1210-0010 197504-1210-003
Historical Active 197504-1210-002
DOL/EBSA
ELIGIBILITY DATA FORM
No material or nonsubstantive change to a currently approved collection   No
Emergency 04/17/1975
Approved with change 04/17/1975
Retrieve Notice of Action (NOA) 04/17/1975
  Inventory as of this Action Requested Previously Approved
12/31/1978 12/31/1978 12/31/1978
3,500 0 10,000
875 0 2,500
0 0 0



None
None


No

1
IC Title Form No. Form Name
ELIGIBILITY DATA FORM LMSA1010

  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 3,500 10,000 0 0 -6,500 0
Annual Time Burden (Hours) 875 2,500 0 0 -1,625 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  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.
04/17/1975


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