Certification of Funeral Expenses

ICR 201506-1240-008

OMB: 1240-0040

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Justification for No Material/Nonsubstantive Change
2014-12-18
Justification for No Material/Nonsubstantive Change
2014-09-30
Supplementary Document
2011-02-28
Supplementary Document
2011-02-09
Supplementary Document
2011-02-09
Supplementary Document
2008-01-09
Supporting Statement A
2014-04-02
IC Document Collections
IC ID
Document
Title
Status
13646 Modified
ICR Details
1240-0040 201506-1240-008
Historical Active 201409-1240-010
DOL/OWCP
Certification of Funeral Expenses
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 06/05/2015
Retrieve Notice of Action (NOA) 06/05/2015
  Inventory as of this Action Requested Previously Approved
05/31/2017 05/31/2017 05/31/2017
75 0 75
19 0 19
34 0 39

Form LS-265 is used to report funeral expenses payable under the Longshore and Harbor Workers' Compensation Act.

US Code: 33 USC 909(a) Name of Law: Longshore and Harbor Workers' Compensation Act
  
None

Final or interim final rulemaking 80 FR 12917 03/12/2015

  78 FR 77169 12/20/2013
79 FR 19923 04/10/2014
No

1
IC Title Form No. Form Name
Certification of Funeral Expenses LS-265 Certification of Funeral Expenses

  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 75 75 0 0 0 0
Annual Time Burden (Hours) 19 19 0 0 0 0
Annual Cost Burden (Dollars) 34 39 0 -5 0 0
No
No

$263
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.
03/12/2015


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