APPLICATION FOR CONTINUATION OF DEATH BENEFIT FOR STUDENT

ICR 197905-1215-001

OMB: 1215-0073

Federal Form Document

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Document
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Status
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IC Document Collections
ICR Details
1215-0073 197905-1215-001
Historical Active 197406-1215-001
DOL/ESA
APPLICATION FOR CONTINUATION OF DEATH BENEFIT FOR STUDENT
Revision of a currently approved collection   No
Regular
Approved without change 05/25/1979
Retrieve Notice of Action (NOA) 05/14/1979
  Inventory as of this Action Requested Previously Approved
05/31/1984 05/31/1984 05/31/1979
50 0 50
25 0 25
0 0 0

REPORT IS A VERIFICATION STATEMENT COMPLETED BY A SCHOOL ATTENDED BY A CLAIMANT (CHILD OF COVERED WORKER) IF THE CLAIMANT IS OVER 18 YEARS OF AGE (PL 92-576).

None
None


No

1
IC Title Form No. Form Name
APPLICATION FOR CONTINUATION OF DEATH BENEFIT FOR STUDENT LS-266

  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 50 50 0 0 0 0
Annual Time Burden (Hours) 25 25 0 0 0 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.
05/14/1979


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