Report of Changes That May Afect Your Black Lung Benefits

ICR 200206-1215-003

OMB: 1215-0084

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
1215-0084 200206-1215-003
Historical Active 199906-1215-002
DOL/ESA
Report of Changes That May Afect Your Black Lung Benefits
Extension without change of a currently approved collection   No
Regular
Approved without change 06/26/2002
Retrieve Notice of Action (NOA) 06/14/2002
  Inventory as of this Action Requested Previously Approved
06/30/2005 06/30/2005 07/31/2002
1 0 30,000
2,208 0 2,650
0 0 0

To help determine continuing eligibility of primary beneficiaries receiving black lung benefits from the Disability Trust Fund. To verify and update on a regular basis factors that affect a beneficiary's entitlement to benefits, including income, marital status, receipt of State Workers' Compensation, and dependent status.

None
None


No

1
IC Title Form No. Form Name
Report of Changes That May Afect Your Black Lung Benefits CM-929

  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 30,000 0 0 -29,999 0
Annual Time Burden (Hours) 2,208 2,650 0 0 -442 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.
06/14/2002


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