Request for Informtion on Earnings, Dual Benefits, Dependents and Third-Party Settlements

ICR 199812-1215-001

OMB: 1215-0151

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
1215-0151 199812-1215-001
Historical Active 199801-1215-004
DOL/ESA
Request for Informtion on Earnings, Dual Benefits, Dependents and Third-Party Settlements
Revision of a currently approved collection   No
Regular
Approved without change 01/28/1999
Retrieve Notice of Action (NOA) 12/01/1998
Approved consistent with clarification in DOL memo of 1-28-99. DOL will provide OMB a copy of the form with the new additions before using the form. Also ESA will meet with OMB within the next three months to discuss the electronic submission of this and other forms used by the agency.
  Inventory as of this Action Requested Previously Approved
01/31/2002 01/31/2002 03/31/2001
50,000 0 50,000
16,667 0 16,667
17,000 0 16,000

This form is used to obtain information from claimants receiving compensation for an extended period of time. This information is necessary to ensure that compensation being paid is correct.

None
None


No

1
IC Title Form No. Form Name
Request for Informtion on Earnings, Dual Benefits, Dependents and Third-Party Settlements 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 50,000 0 0 0 0
Annual Time Burden (Hours) 16,667 16,667 0 0 0 0
Annual Cost Burden (Dollars) 17,000 16,000 0 1,000 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.
12/01/1998


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