Survivor's Form for Benefits

ICR 200703-1215-004

OMB: 1215-0069

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supplementary Document
2007-03-07
Supplementary Document
2007-03-07
Supporting Statement A
2007-05-30
IC Document Collections
IC ID
Document
Title
Status
13721 Modified
ICR Details
1215-0069 200703-1215-004
Historical Active 200406-1215-005
DOL/ESA
Survivor's Form for Benefits
Extension without change of a currently approved collection   No
Regular
Approved without change 08/27/2007
Retrieve Notice of Action (NOA) 06/14/2007
  Inventory as of this Action Requested Previously Approved
08/31/2010 36 Months From Approved 08/31/2007
2,000 0 2,800
267 0 373
704 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.

US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
  
None

Not associated with rulemaking

  72 FR 9975 03/06/2007
72 FR 32865 06/14/2007
No

1
IC Title Form No. Form Name
Survivor's Form for Benefits CM-912 Survivor's Form For Benefits Under The Black Lung Benefits Act

  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 2,000 2,800 0 0 -800 0
Annual Time Burden (Hours) 267 373 0 0 -106 0
Annual Cost Burden (Dollars) 704 1,000 0 0 -296 0
No
No
There is a decrease in the approximate number of respondents from 2,800 to 2,000, due to the mortality rate of an aging claimant population. Accordingly, there is an adjustment of burden hours from 373 to 267 is a decrease of -106 hours and cost burden from $1,000 to $704.

$19,862
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Michael McClaran 202-693-0978 [email protected]

  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.
06/14/2007


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