Information Collection

Miner's Claim for Benefits under the Black Lung Benefits Act, Employment History, Miner Reimbursement Form

IC 13677 under ICR 199602-1215-003 · OMB 1215-0052.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1215-0052 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Miner's Claim for Benefits under the Black Lung Benefits Act, Employment History, Miner Reimbursement Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	CM-915	No	No
Form	CM-911A	No	No
Form	CM-911	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20,200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	20,200	0	-32,500	52,700
Annual IC Time Burden (Hours)	9,116	0	-5,417	14,533
Annual IC Cost Burden (Dollars)	3,000	3,000	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.