APPLICATION FOR LUMP SUM AWARD

ICR 197907-1215-001

OMB: 1215-0076

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
122079 Migrated
ICR Details
1215-0076 197907-1215-001
Historical Active 197408-1215-001
DOL/ESA
APPLICATION FOR LUMP SUM AWARD
Revision of a currently approved collection   No
Regular
Approved without change 08/20/1979
Retrieve Notice of Action (NOA) 07/18/1979
  Inventory as of this Action Requested Previously Approved
08/31/1984 08/31/1984 08/31/1979
20 0 15
10 0 15
0 0 0

REPORT IS USED BY CLAIMANTS OF LHWC BENEFITS TO APPLY FOR A LUMP SUM AWARD (AT A DISCOUNT) PL 92-576, SECTION 14J).

None
None


No

1
IC Title Form No. Form Name
APPLICATION FOR LUMP SUM AWARD LS-221

  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 20 15 0 0 5 0
Annual Time Burden (Hours) 10 15 0 0 -5 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.
07/18/1979


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