Information Collection

EEOICP Forms for State Governments

IC 178684 under ICR 201610-1240-003 · OMB 1240-0002.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0002 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form EE-13 with EN-13 EEOICP Forms for State Governments	Form
EE-13 with EN-13 Letter to State Workers' Compensation EE-13 with EN-13.doc	Form

IC Title:

EEOICP Forms for State Governments

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	EE-13 with EN-13	Letter to State Workers' Compensation	EE-13 with EN-13.doc		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: DOL/ESA-49

FR Citation: 67 FR 16891

Number of Respondents: 51

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	51	-2,387	2,438
Annual IC Time Burden (Hours)	816	-1,017	1,833
Annual IC Cost Burden (Dollars)	26	-1,169	1,195

Documents for IC

table that charts IC Documents
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.