Application for Continuation of Death Benefit for Student

ICR 201409-1240-011

OMB: 1240-0026

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Justification for No Material/Nonsubstantive Change
2014-09-30
Supporting Statement A
2014-01-30
Supplementary Document
2013-11-12
Supplementary Document
2013-11-12
IC Document Collections
ICR Details
1240-0026 201409-1240-011
Historical Active 201311-1240-002
DOL/OWCP
Application for Continuation of Death Benefit for Student
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 10/07/2014
Retrieve Notice of Action (NOA) 09/30/2014
  Inventory as of this Action Requested Previously Approved
03/31/2017 03/31/2017 03/31/2017
20 0 20
10 0 10
10 0 10

Form LS-266 is used as an application for continuation of death benefits for a dependent who is a student.

US Code: 33 USC 902(18) Name of Law: The Longshore and Harbor Workers' Compensation Act
   US Code: 33 USC 939(a) Name of Law: The Longshore and Harbor Workers' Compensation Act
  
None

Not associated with rulemaking

  78 FR 68867 11/15/2013
79 FR 9925 02/21/2014
No

1
IC Title Form No. Form Name
Application for Continuation of Death Benefit for Student ls-266 dev Application for Continuation of Death Benefit for Student

  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 20 20 0 0 0 0
Annual Time Burden (Hours) 10 10 0 0 0 0
Annual Cost Burden (Dollars) 10 10 0 0 0 0
No
No
There has been a decrease in burden from 22 hours to 10 hours due to a decrease in the number of forms received. The decrease in operation and maintenance cost from $20.68 to $9.80 is also due to a decrease in the number of forms received.

$73
No
No
No
No
No
Uncollected
Cheryl Jordan 202 693-0289 [email protected]

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
09/30/2014


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