Information Collection

Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act

IC 13940 under ICR 200612-1215-003 · OMB 1215-0202.

Documents and Forms

Document Name Document Type
Form CA-278 Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act Form
CA-278 Claim for Reimbursement of Benefit Payments and Claims E ca-278.pdf www.dol.gov/esa/regs/compliance/owcp/ca-278.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 61.104 20 CFR 61.101

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CA-278	Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act	ca-278.pdf	http://www.dol.gov/esa/regs/compliance/owcp/ca-278.pdf	No		Printable Only

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	140	60	80
Annual IC Time Burden (Hours)	70	30	40
Annual IC Cost Burden (Dollars)	239	239	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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