Application for Continuation of Death Benefit for Student

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0026 can be found here:

Documents and Forms

Document Name Document Type
Form ls-266 dev Application for Continuation of Death Benefit for Student Form and Instruction
ls-266 dev Application for Continuation of Death Benefit for Studen ls-266 dev.pdf www.dol.gov/owcp/dlhwc/ls-266.pdf Form and Instruction
DLHWC Seaportal.pdf DLHWC SEA Portal IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for Continuation of Death Benefit for Student	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 702.121

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	ls-266 dev	Application for Continuation of Death Benefit for Student	ls-266 dev.pdf	http://www.dol.gov/owcp/dlhwc/ls-266.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/ESA-15	FR Citation: 67 FR 16870

Number of Respondents: 20	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	10	10

Documents for IC

Title	Document	Date Uploaded
DLHWC SEA Portal	DLHWC Seaportal.pdf	09/24/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.