Survivor's Notification of Beneficiary's Death

ICR 199506-1215-005

OMB: 1215-0087

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
122126 Migrated
ICR Details
1215-0087 199506-1215-005
Historical Active 199207-1215-001
DOL/ESA
Survivor's Notification of Beneficiary's Death
Extension without change of a currently approved collection   No
Regular
Approved without change 08/28/1995
Retrieve Notice of Action (NOA) 06/21/1995
None
  Inventory as of this Action Requested Previously Approved
08/31/1998 08/31/1998 09/30/1995
2,100 0 0
280 0 333
0 0 0

The CM-1089 is used to gather information from a beneficiary's survivor to ensure that benefits due on behalf of a deceased miner are accurate for continuation of benefits.

None
None


No

1
IC Title Form No. Form Name
Survivor's Notification of Beneficiary's Death CM-1089

  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 2,100 0 0 0 2,100 0
Annual Time Burden (Hours) 280 333 0 0 -53 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.
06/21/1995


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