Claim for Continuance of Compensation

ICR 199903-1215-003

OMB: 1215-0154

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
13836 Migrated
ICR Details
1215-0154 199903-1215-003
Historical Active 199602-1215-006
DOL/ESA
Claim for Continuance of Compensation
Revision of a currently approved collection   No
Regular
Approved without change 05/24/1999
Retrieve Notice of Action (NOA) 03/26/1999
  Inventory as of this Action Requested Previously Approved
05/31/2002 05/31/2002 05/31/1999
6,054 0 6,537
505 0 545
2,000 0 2,000

This form is used to obtain information on marital status of beneficiaries in death cases, in order to determine continued entitlement to benefits under the provisions of the Federal Employees' Compensation Act.

None
None


No

1
IC Title Form No. Form Name
Claim for Continuance of Compensation CA-12

  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 6,054 6,537 0 0 -483 0
Annual Time Burden (Hours) 505 545 0 0 -40 0
Annual Cost Burden (Dollars) 2,000 2,000 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.
03/26/1999


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