REPORT OF CHANGES THAT MAY AFFECT YOUR DEPARTMENT OF LABOR BLACK LUNG PAYMENT

ICR 198505-1215-001

OMB: 1215-0084

Federal Form Document

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Name
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ICR Details
1215-0084 198505-1215-001
Historical Active 198302-1215-001
DOL/ESA
REPORT OF CHANGES THAT MAY AFFECT YOUR DEPARTMENT OF LABOR BLACK LUNG PAYMENT
Revision of a currently approved collection   No
Regular
Approved without change 07/08/1985
Retrieve Notice of Action (NOA) 05/14/1985
  Inventory as of this Action Requested Previously Approved
07/31/1988 07/31/1988 07/31/1985
97,000 0 93,000
12,610 0 12,090
0 0 0

TO HELP DETERMINE CONTINUED ELIGIBILITY OF PRIMARY BENEFICIARIES AND DEPENDENTS RECEIVING SEPARATE CHECKS (SPLIT PAYEES) FROM THE TRUST FUN TO VERIFY AND UPDATE ON AN ANNUAL BASIS INCOME, MARITAL STATUS, AND DEPENDENCY STATUS.

None
None


No

1
IC Title Form No. Form Name
REPORT OF CHANGES THAT MAY AFFECT YOUR DEPARTMENT OF LABOR BLACK LUNG PAYMENT CM-929

  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 97,000 93,000 0 4,000 0 0
Annual Time Burden (Hours) 12,610 12,090 0 520 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
05/14/1985


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