SURVIVOR'S CLAIM FOR BENEFITS UNDER THE BLACK LUNG BENEFITS ACT

ICR 198905-1215-003

OMB: 1215-0069

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
1215-0069 198905-1215-003
Historical Active 198904-1215-019
DOL/ESA
SURVIVOR'S CLAIM FOR BENEFITS UNDER THE BLACK LUNG BENEFITS ACT
Revision of a currently approved collection   No
Regular
Approved without change 08/01/1989
Retrieve Notice of Action (NOA) 05/04/1989
  Inventory as of this Action Requested Previously Approved
07/31/1992 07/31/1992 07/31/1989
1,500 0 2,350
630 0 783
0 0 0

A SURVIVOR OF A COAL MINER MUST FILE A CLAIM FOR BENEFITS UNDER THE BLACK LUNG BENEFITS ACT AS AMENDED, IN ORDER TO RECEIVE BENEFITS. THE CLAIMS AND SUPPORTING DOCUMENTATION ARE REVIEWED BY DCMWC CLAIMS EXAMINERS TO DETERMINE THE SURVIVOR'S ELIGIBILITY FOR BENEFITS.

None
None


No

1
IC Title Form No. Form Name
SURVIVOR'S CLAIM FOR BENEFITS UNDER THE BLACK LUNG BENEFITS ACT CM-912

  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 1,500 2,350 0 722 -1,572 0
Annual Time Burden (Hours) 630 783 0 130 -283 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.
05/04/1989


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