Information Collection

Certification of Funeral Expenses

IC 13646 under ICR 200709-1215-005 · OMB 1215-0027.

Documents and Forms

Document Name Document Type
Form LS-265 Certification of Funeral Expenses Form
LS-265 Certification of Funeral Expenses ls-265.pdf www.dol.gov/esa/owcp/dlhwc/ls-265.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Certification of Funeral Expenses	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	LS-265	Certification of Funeral Expenses	ls-265.pdf	http://www.dol.gov/esa/owcp/dlhwc/ls-265.pdf	Yes	No	Fillable Printable

Line of Business: Workforce Management

Subfunction: Worker Safety

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

Number of Respondents: 195	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	195	0	195
Annual IC Time Burden (Hours)	49	0	49
Annual IC Cost Burden (Dollars)	86	86	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.