Application for Benefits Under The Federal Mine Safety and Health Act of 1977, as Amended (Widow's Claim, Child's Claim and Dependent's Claim

ICR 200102-0960-009

OMB: 0960-0118

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0960-0118 200102-0960-009
Historical Active 199801-0960-009
SSA
Application for Benefits Under The Federal Mine Safety and Health Act of 1977, as Amended (Widow's Claim, Child's Claim and Dependent's Claim
Extension without change of a currently approved collection   No
Regular
Approved without change 04/12/2001
Retrieve Notice of Action (NOA) 02/28/2001
  Inventory as of this Action Requested Previously Approved
04/30/2004 04/30/2004 04/30/2001
1,800 0 1,800
330 0 330
0 0 0

Forms SSA-47-F4, SSA-48-F4, and SSA-49-F3 are used by SSA to determine eligibility for benefits under the Federal Mine Safety and Health Act of 1977. The respondents are widows, surviving children and dependents (parents, brothers or sisters) who are not currently receiving Black Lung benefits on the deceased miner's account.

None
None


No

1
IC Title Form No. Form Name
Application for Benefits Under The Federal Mine Safety and Health Act of 1977, as Amended (Widow's Claim, Child's Claim and Dependent's Claim SSA-47-F4, SSA-48-F4, SSA-49-F3

  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 1,800 1,800 0 0 0 0
Annual Time Burden (Hours) 330 330 0 0 0 0
Annual Cost Burden (Dollars) 0 0 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.
02/28/2001


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