Information Collection

1) Miner's Claim for Benefits under the Black Lung Benefits Act; 2) Employment History; 3) Miner Reimbursement Form

IC 13678 under ICR 199903-1215-004 · OMB 1215-0052.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	1) Miner's Claim for Benefits under the Black Lung Benefits Act; 2) Employment History; 3) 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-911	No	No
Form	CM-911A	No	No
Form	CM-915	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	20,200	0	20,200
Annual IC Time Burden (Hours)	9,116	0	9,116
Annual IC Cost Burden (Dollars)	4,000	1,000	3,000

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.