REQUEST FROM CLAIMANT FOR INFORMATION ON EARNINGS, DUAL BENEFITS, AND THIRD PARTY SETTLEMENT

ICR 198812-1215-002

OMB: 1215-0151

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
1215-0151 198812-1215-002
Historical Active 198602-1215-001
DOL/ESA
REQUEST FROM CLAIMANT FOR INFORMATION ON EARNINGS, DUAL BENEFITS, AND THIRD PARTY SETTLEMENT
Extension without change of a currently approved collection   No
Regular
Approved without change 02/06/1989
Retrieve Notice of Action (NOA) 12/20/1988
  Inventory as of this Action Requested Previously Approved
02/28/1992 02/28/1992 03/31/1989
38,000 0 38,000
12,667 0 12,667
0 0 0

T CA-1032 IS USED TO OBTAIN INFORMATION FROM CLAIMANTS RECEIVING COMPENSATION ON THE DIVISION OF FEDERAL EMPLOYEES' COMPENSATION PERIODIC DISABILITY ROLL. THIS INFORMATION IS NECESSARY TO ENSURE THA THE COMPENSATION BEING PAID IS CORRECT.

None
None


No

1
IC Title Form No. Form Name
REQUEST FROM CLAIMANT FOR INFORMATION ON EARNINGS, DUAL BENEFITS, AND THIRD PARTY SETTLEMENT CA-1032

  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 38,000 38,000 0 0 0 0
Annual Time Burden (Hours) 12,667 12,667 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.
12/20/1988


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