Application for Continuation of Death Benefit for Student

ICR 200110-1215-001

OMB: 1215-0073

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
1215-0073 200110-1215-001
Historical Active 199811-1215-001
DOL/ESA
Application for Continuation of Death Benefit for Student
Extension without change of a currently approved collection   No
Regular
Approved without change 12/11/2001
Retrieve Notice of Action (NOA) 10/15/2001
  Inventory as of this Action Requested Previously Approved
12/31/2004 12/31/2004 01/31/2002
43 0 43
22 0 22
0 0 0

This form is used as an application for continuation of death benefits for a dependent who is a student.

None
None


No

1
IC Title Form No. Form Name
Application for Continuation of Death Benefit for Student LS-266

  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 43 43 0 0 0 0
Annual Time Burden (Hours) 22 22 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.
10/15/2001


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