Maintenance of Receipt for Benefits Paid by a Coal Mine Operator

ICR 200104-1215-001

OMB: 1215-0124

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
1215-0124 200104-1215-001
Historical Active 199807-1215-009
DOL/ESA
Maintenance of Receipt for Benefits Paid by a Coal Mine Operator
Extension without change of a currently approved collection   No
Regular
Approved without change 06/20/2001
Retrieve Notice of Action (NOA) 04/23/2001
  Inventory as of this Action Requested Previously Approved
06/30/2004 06/30/2004 09/30/2001
150 0 150
1 0 1
0 0 0

CFR 725.531 requires self-insured operators or insurance carriers who make benefit payments to black lung beneficiaries to maintain receipts for thos payments for five (5) years. Cancelled checks will suffice.

None
None


No

1
IC Title Form No. Form Name
Maintenance of Receipt for Benefits Paid by a Coal Mine Operator CM-200

  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 150 150 0 0 0 0
Annual Time Burden (Hours) 1 1 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.
04/23/2001


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