Information Collection

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

IC 9090 under ICR 200102-0960-009 · OMB 0960-0118.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0118 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	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	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	SSA-48-F4	No	No
Form	SSA-47-F4	No	No
Form	SSA-49-F3	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,800	1,800
Annual IC Time Burden (Hours)	330	330
Annual IC Cost Burden (Dollars)	0	0

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.