APPLICATION FOR LUMP SUM AWARD

ICR 198407-1215-006

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
122080 Migrated
ICR Details
1215-0076 198407-1215-006
Historical Active 198107-1215-013
DOL/ESA
APPLICATION FOR LUMP SUM AWARD
Revision of a currently approved collection   No
Regular
Approved without change 07/20/1984
Retrieve Notice of Action (NOA) 07/16/1984
  Inventory as of this Action Requested Previously Approved
07/31/1987 07/31/1987 07/31/1984
17 0 20
10 0 10
0 0 0

FORM IS USED BY CLAIMANTS TO REQUEST LUMP SUM AWARDS UNDER THE LONGSHOREMEN'S AND HARBOR WORKERS' COMPENSATION ACT.

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 17 20 0 -3 0 0
Annual Time Burden (Hours) 10 10 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.
07/16/1984


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