Information Collection

Survivor's Form for Benefits

IC 13721 under ICR 200703-1215-004 · OMB 1215-0069.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CM-912 Survivor's Form for Benefits	Form
CM-912 Survivor's Form For Benefits Under The Black Lung Benefi cm-912.pdf www.dol.gov/esa/regs/compliance/owcp/cm-912.pdf	Form

IC Title:

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 410.221 20 CFR 725.304

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-912	Survivor's Form For Benefits Under The Black Lung Benefits Act	cm-912.pdf	http://www.dol.gov/esa/regs/compliance/owcp/cm-912.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records

Title: ESA-6 (67 FR 16869) and ESA-30 (67 FR 16878)

FR Citation: 67 FR 16869

Number of Respondents: 2,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,000	-800	2,800
Annual IC Time Burden (Hours)	267	-106	373
Annual IC Cost Burden (Dollars)	704	-296	1,000

Documents for IC

table that charts IC Documents
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.