Survivor's Form for Benefits

Forms and Documents

Document Name	Status
Form CM-912 Survivor's Form for Benefits Form	Modified
DOL Privacy Act systems ESA-30.pdf Supplementary Document	2007-03-07
DOL Privacy Act systems ESA-6.pdf Supplementary Document	2007-03-07
SS for 1215-0069 (CM-912) February 2007.doc Supporting Statement A	2007-05-30

IC Document Collections

IC ID	Document Title	Status
13721	Survivor's Form for Benefits Form	Modified

ICR Details

OMB Control No: 1240-0027	ICR Reference No: 201003-1240-027
Status: Historical Active	Previous ICR Reference No: 200406-1215-005
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Survivor's Form for Benefits
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/12/2010
	Date Received in OIRA: 03/12/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2010	36 Months From Approved
Responses	2,000	0	2,800
Time Burden (Hours)	267	0	373
Cost Burden (Dollars)	704	0	1,000

---

Abstract: The CM-912 is used to gather information from a beneficiary's survivor to determine if the survivor is entitled to benefits or the continuation of benefits.

---

Authorizing Statute(s): US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 9975	03/06/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 32865	06/14/2007
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Survivor's Form for Benefits	CM-912	Survivor's Form For Benefits Under The Black Lung Benefits Act

---

ICR Summary of Burden

	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	2,000	2,800	0	0	-800	0
Annual Time Burden (Hours)	267	373	0	0	-106	0
Annual Cost Burden (Dollars)	704	1,000	0	0	-296	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There is a decrease in the approximate number of respondents from 2,800 to 2,000, due to the mortality rate of an aging claimant population. Accordingly, there is an adjustment of burden hours from 373 to 267 is a decrease of -106 hours and cost burden from $1,000 to $704.

---

Annual Cost to Federal Government: $19,862

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 06/14/2007

---