Survivor's Form for Benefits

ICR 199806-1215-001

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
IC ID
Document
Title
Status
13719 Migrated
ICR Details
1215-0069 199806-1215-001
Historical Active 199601-1215-002
DOL/ESA
Survivor's Form for Benefits
Revision of a currently approved collection   No
Regular
Approved without change 08/18/1998
Retrieve Notice of Action (NOA) 06/09/1998
Approved on the condition that DOL provide a response to questions raised on July 24 by OMB, addressing the utility of certain data elements that are proposed for deletion. Prior to implementation of the new form, DOL will respond to these questions and resolve any issues that remain.
  Inventory as of this Action Requested Previously Approved
08/31/2001 08/31/2001 03/31/1999
3,300 0 1,200
440 0 500
1,000 0 0

Under 20 CFR 725.212, the CM-912 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. Under 20 CFR part 718, the CM-912 is used as an application for survivors under the Black Lung Benefits Act. The application and any supporting documentation specifies that certain information relative to the claimant's relationship be established, if not already proven, and the medical condition of any decedent miner alleged to have died or been totally disabled at time of death, in whole or in part.

None
None


No

1
IC Title Form No. Form Name
Survivor's Form for Benefits 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 3,300 1,200 0 11,900 -9,800 0
Annual Time Burden (Hours) 440 500 0 -340 280 0
Annual Cost Burden (Dollars) 1,000 0 0 1,000 0 0
No
Yes

$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.
06/09/1998


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