Application for Continuation of Death Benefit for Student

ICR 200708-1215-003

OMB: 1215-0073

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supplementary Document
2007-09-20
Supplementary Document
2007-09-20
Supplementary Document
2007-09-20
Supporting Statement A
2008-01-15
IC Document Collections
ICR Details
1215-0073 200708-1215-003
Historical Active 200410-1215-001
DOL/ESA
Application for Continuation of Death Benefit for Student
Extension without change of a currently approved collection   No
Regular
Approved with change 01/17/2008
Retrieve Notice of Action (NOA) 10/26/2007
  Inventory as of this Action Requested Previously Approved
01/31/2011 36 Months From Approved 01/31/2008
43 0 43
22 0 22
19 0 0

The Form LS-266 is used as an application for continuation of death benefits for a dependent who is a student.

US Code: 33 USC 939(a) Name of Law: The Longshore and Harbor Workers' Compensation Act
   US Code: 33 USC 902(18) Name of Law: The Longshore and Harbor Workers' Compensation Act
  
None

Not associated with rulemaking

  72 FR 47079 08/22/2007
72 FR 60889 10/26/2007
No

1
IC Title Form No. Form Name
Application for Continuation of Death Benefit for Student LS-266 Application for Continuation of Death Benefit for Student

  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 43 43 0 0 0 0
Annual Time Burden (Hours) 22 22 0 0 0 0
Annual Cost Burden (Dollars) 19 0 0 0 19 0
No
No

$128
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Cheryl Jordan 202 693-0289 [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.
10/26/2007


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