Information Collection

Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor

IC 13877 under ICR 201011-1240-001 · OMB 1240-0011.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0011 can be found here:

Documents and Forms

Document Name Document Type
Form CM-972 Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor Form
CM-972 Application for Approval of a Representative's Fee in a cm-972(Expires 12-31-2010).pdf www.dol.gov/owcp/regs/compliance/cm-972.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor	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 725.366 20 CFR 725.365

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-972	Application for Approval of a Representative's Fee in a Black Lung Claim Proceeding Conducted by the U.S. Department of Labor	cm-972(Expires 12-31-2010).pdf	http://www.dol.gov/owcp/regs/compliance/cm-972.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title: DOL/ESA-6	FR Citation: 67 FR 16869

Number of Respondents: 285	Number of Respondents for Small Entity: 276

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	285	285
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	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.