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

ICR 199112-1215-002

OMB: 1215-0151

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
1215-0151 199112-1215-002
Historical Active 198812-1215-002
DOL/ESA
REQUEST FROM CLAIMANT FOR INFORMATION ON EARNINGS, DUAL BENEFITS, DEPENDENTS, AND THIRD-PARTY SETTLEMENT
Revision of a currently approved collection   No
Regular
Approved without change 03/13/1992
Retrieve Notice of Action (NOA) 12/09/1991
  Inventory as of this Action Requested Previously Approved
04/30/1995 04/30/1995 02/28/1992
50,000 0 38,000
16,667 0 12,667
0 0 0

THE CA-1032 IS USED TO OBTAIN INFORMATION FROM CLAIMANTS RECEIVING COMPENSATION ON THE DIVISION OF FEDERAL EMPLOYEES' COMPENSATION PERIOD DISABILITY ROLL. THIS INFORMATION IS NECESSARY TO ENSURE THAT 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, DEPENDENTS, 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 50,000 38,000 0 0 12,000 0
Annual Time Burden (Hours) 16,667 12,667 0 0 4,000 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.
12/09/1991


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