Information Collection

Application for Benefits Under The Federal Mine Safety and Dependent's Claim

IC 37953 under ICR 200109-0960-025 · OMB 0960-0118.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

Application for Benefits Under The Federal Mine Safety and 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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	SSA-49-F3	No	No
Form	SSA-48-F4	No	No
Form	SSA-47-F4	No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	300	-1,500	1,800
Annual IC Time Burden (Hours)	165	-165	330
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.