Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor

ICR 201611-1240-001

OMB: 1240-0011

Federal Form Document

ICR Details
1240-0011 201611-1240-001
Historical Active 201309-1240-002
DOL/OWCP
Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor
Extension without change of a currently approved collection   No
Regular
Approved without change 05/30/2017
Retrieve Notice of Action (NOA) 03/07/2017
  Inventory as of this Action Requested Previously Approved
05/31/2020 36 Months From Approved 05/31/2017
338 0 338
237 0 237
169 0 0

The purpose of the CM-972 is to collect pertinent data to determine if the representative's services and the amounts charged can be paid under the Black Lung Benefits Act.

US Code: 30 USC 932 Name of Law: Black Lung Benefits Act
   US Code: 30 USC 936 Name of Law: Black Lung Benefits Act
   US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
  
None

Not associated with rulemaking

  81 FR 78862 11/09/2016
82 FR 12848 03/07/2017
No

  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 338 338 0 0 0 0
Annual Time Burden (Hours) 237 237 0 0 0 0
Annual Cost Burden (Dollars) 169 0 0 0 169 0
No
No

$6,495
No
No
No
No
No
Uncollected
Debbie Thurston 202 693-0913 [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.
03/07/2017


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