Information Collection

Statement of Recovery

IC 188783 under ICR 201202-1240-002 · OMB 1240-0001.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0001 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form ca-1122 Statement of Recovery	Form and Instruction
ca-1122 Statement of Recovery CA-1122 mjs final with accomodation statement-4-20-12.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction

IC Title:

Statement of Recovery

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 10.710 20 CFR 10.707 (e)

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-1122	Statement of Recovery	CA-1122 mjs final with accomodation statement-4-20-12.pdf	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Central Personnel

Privacy Act System of Records

Title: DOL/GOVT-1 (Office of Worker's Compensation Programs, Federal Employees' Compemsation Act File

FR Citation: 67 FR 16827

Number of Respondents: 283

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	283	-17	300
Annual IC Time Burden (Hours)	71	-4	75
Annual IC Cost Burden (Dollars)	136	1	135

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.