Survivor's Form for Benefits

Survivor's Form for Benefits

OMB: 1215-0069

IC ID: 13721

Information Collection (IC) Details

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Survivor's Form for Benefits
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 410.221 20 CFR 725.304

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

Income Security Survivor Compensation

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

2,000 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,000 0 0 -800 0 2,800
Annual IC Time Burden (Hours) 267 0 0 -106 0 373
Annual IC Cost Burden (Dollars) 704 0 0 -296 0 1,000

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