Information Collection

Application for Continuation of Death Benefit for Student

IC 13739 under ICR 200708-1215-003 · OMB 1215-0073.

Documents and Forms

Document Name Document Type
Form LS-266 Application for Continuation of Death Benefit for Student Form and Instruction
LS-266 Application for Continuation of Death Benefit for Studen ls-266.pdf www.dol.gov/esa/owcp/dlhwc/ls-266.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for Continuation of Death Benefit for Student	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 702.121

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	LS-266	Application for Continuation of Death Benefit for Student	ls-266.pdf	http://www.dol.gov/esa/owcp/dlhwc/ls-266.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title: DOL/ESA-15	FR Citation: 58 FR 49599

Number of Respondents: 43	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	43	0	43
Annual IC Time Burden (Hours)	22	0	22
Annual IC Cost Burden (Dollars)	19	19	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.