Representative Fee Request

Forms and Documents

Document Name	Status
Form CA-143 and CA-155 Representative Fee Request Form and Instruction	Modified
summary of changes CA-143.doc Supplementary Document	2012-10-26
Section 928 Fees for Services-Longshore.doc Supplementary Document	2012-09-20
Sections 10. 700 through 10. 703.doc Supplementary Document	2012-09-20
Electronic Code of Federal Regulations-702.132.mht Supplementary Document	2012-09-20
OMB - Supporting Statement for 1240-0049 (CA-143).doc Supporting Statement A	2013-01-18

IC Document Collections

IC ID	Document Title	Status
13744	Representative Fee Request Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0049	ICR Reference No: 201209-1240-005
Status: Historical Active	Previous ICR Reference No: 201003-1240-049
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Representative Fee Request
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/29/2013
	Date Received in OIRA: 12/14/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2016	36 Months From Approved	01/31/2013
Responses	12,363	0	8,404
Time Burden (Hours)	6,182	0	5,419
Cost Burden (Dollars)	15,696	0	12,806

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Abstract: Individuals filing for compensation benefits with the Office of Workers' Compensation Programs (OWCP) may be represented by an attorney or other representative. The representative is entitled to request a fee for services under the Federal Employees' Compensation Act (FECA) and under the Longshore and Harbor Workers' Compensation Act (LHWCA). The fee must be approved by the OWCP before any demand for payment can be made by the representative. This information collection request sets forth the criteria for the information, which must be presented by the respondent in order to have the fee approved by the OWCP. The information collection does not have a particular form or format; the respondent must present the information in any format which is convenient and which meets all the required information criteria.

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Authorizing Statute(s): US Code: 5 USC 8101 et seq Name of Law: Federal Employees' Compensation Act
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 51829	08/27/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 74514	12/14/2012
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Representative Fee Request	CA-143 and CA-155	Attorney Fee Request

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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	12,363	8,404	0	0	3,959	0
Annual Time Burden (Hours)	6,182	5,419	0	0	763	0
Annual Cost Burden (Dollars)	15,696	12,806	0	0	2,890	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: The previously approved number of respondents of 8,404 is increased to 12,363, an increase of 3,959. Consequently, burden hours of 5,419 are now adjusted to 6,182, an increase of 763. The adjustments are due to an increase in reporting of lost time injuries under the Longshore Act. Likewise, previous burden costs of 12,806 is now adjusted to 15,696, an increase of 2,890, as a result in the increase of reported injuries as well as maintenance and reporting costs.

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Annual Cost to Federal Government: $272,433

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 12/14/2012

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