Request for Earnings Information

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0025 can be found here:

Documents and Forms

Document Name Document Type
Form LS-426 Request for Earnings Information Form
LS-426 Request for Earnings Information ls-426 dev.pdf www.dol.gov/owcp/dlhwc/ls-426.pdf Form
DLHWC Seaportal.pdf DLHWC SEA Portal IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for Earnings Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	LS-426	Request for Earnings Information	ls-426 dev.pdf	http://www.dol.gov/owcp/dlhwc/ls-426.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 16886

Number of Respondents: 1,100	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	1,100	1,100
Annual IC Time Burden (Hours)	275	275
Annual IC Cost Burden (Dollars)	528	528

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.