Information Collection

Certification of Funeral Expenses

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.