Survivor's Form for Benefits

ICR 200406-1215-005

OMB: 1215-0069

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
13721 Migrated
ICR Details
1215-0069 200406-1215-005
Historical Active 200106-1215-002
DOL/ESA
Survivor's Form for Benefits
Extension without change of a currently approved collection   No
Regular
Approved without change 08/04/2004
Retrieve Notice of Action (NOA) 06/15/2004
  Inventory as of this Action Requested Previously Approved
08/31/2007 08/31/2007 08/31/2004
2,800 0 2,500
373 0 333
1,000 0 1,000

The CM-912 is used to gather information from a beneficiary's survivor to determine if the survivor is entitled to benefits or the continuation of benefits.

None
None


No

1
IC Title Form No. Form Name
Survivor's Form for Benefits CM-912

  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 2,800 2,500 0 300 0 0
Annual Time Burden (Hours) 373 333 0 40 0 0
Annual Cost Burden (Dollars) 1,000 1,000 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.
06/15/2004


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