Statement of Recovery Forms

ICR 200304-1215-001

OMB: 1215-0200

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
13937 Migrated
ICR Details
1215-0200 200304-1215-001
Historical Active
DOL/ESA
Statement of Recovery Forms
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 07/14/2003
Retrieve Notice of Action (NOA) 04/11/2003
  Inventory as of this Action Requested Previously Approved
07/31/2006 07/31/2006
3,200 0 0
1,520 0 0
0 0 0

These forms are used to obtain information about amounts received as the result of a final judgemnt in litigation, or a settlement of the litigation, brough against a third party who is liable for damages due to a compensation work-related injury.

None
None


No

1
IC Title Form No. Form Name
Statement of Recovery Forms CA/EN-1108, EB/EN-1108, CA/EN-1122

  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 3,200 0 0 3,200 0 0
Annual Time Burden (Hours) 1,520 0 0 1,520 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
04/11/2003


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