Certification of Funeral Expenses

ICR 200709-1215-005

OMB: 1215-0027

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supplementary Document
2008-01-09
Supplementary Document
2008-01-09
Supplementary Document
2008-01-09
Supporting Statement A
2008-01-18
IC Document Collections
IC ID
Document
Title
Status
13646 Modified
ICR Details
1215-0027 200709-1215-005
Historical Active 200502-1215-002
DOL/ESA
Certification of Funeral Expenses
Extension without change of a currently approved collection   No
Regular
Approved without change 02/26/2008
Retrieve Notice of Action (NOA) 01/25/2008
  Inventory as of this Action Requested Previously Approved
02/28/2011 36 Months From Approved 04/30/2008
195 0 195
49 0 49
86 0 0

This form is used to report funeral expenses payable under the Longshore and Harbor Workers' Act.

US Code: 33 USC 909(a) Name of Law: Longshore and Harbor Workers' Compensation Act
  
None

Not associated with rulemaking

  72 FR 54463 09/25/2007
73 FR 4633 01/25/2008
No

1
IC Title Form No. Form Name
Certification of Funeral Expenses LS-265 Certification of Funeral Expenses

  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 195 195 0 0 0 0
Annual Time Burden (Hours) 49 49 0 0 0 0
Annual Cost Burden (Dollars) 86 0 0 0 86 0
No
No

$578
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.
01/25/2008


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