Information Collection

Representative Fee Request

IC 13744 under ICR 200908-1215-003 · OMB 1215-0078.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form ca-143 Representative Fee Request	Form and Instruction
ca-143 attorney fee request ca-143 10-29-09 for 1215-0078.doc	Form and Instruction

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 10.700-703 20 CFR 702.132

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 and Instruction	ca-143	attorney fee request	ca-143 10-29-09 for 1215-0078.doc		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: DOL-ESA Notice 15 and DOL/GOVT-1

FR Citation: 58 FR 49599

Number of Respondents: 8,404

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	8,404	-3,936	12,340
Annual IC Time Burden (Hours)	5,419	-2,256	7,675
Annual IC Cost Burden (Dollars)	12,806	-4,595	17,401

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.