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

⚠️ Notice: This information collection may be referencing outdated material.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_working.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_working.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: 338	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	338	53	285
Annual IC Time Burden (Hours)	237	37	200
Annual IC Cost Burden (Dollars)	0	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.