Information Collection

Notice of Final Payment or Suspension of Compensation Benefits

IC 13642 under ICR 201611-1240-003 · OMB 1240-0041.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0041 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form LS-208 Notice of Final Payment or Suspension of Compensation Benefits	Form
LS-208 Notice of Final Payment or Suspension of Compensation Be ls-208 proposed.pdf www.dol.gov/owcp/dlhwc/ls-208.pdf	Form
DLHWC Seaportal.pdf DLHWC SEA Portal	IC Document

IC Title:

Notice of Final Payment or Suspension of Compensation Benefits

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 702.235 20 CFR 702.236

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	LS-208	Notice of Final Payment or Suspension of Compensation Benefits	ls-208 proposed.pdf	http://www.dol.gov/owcp/dlhwc/ls-208.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: 600

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 1 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	21,000	21,000
Annual IC Time Burden (Hours)	5,250	5,250
Annual IC Cost Burden (Dollars)	9,500	9,500

Documents for IC

table that charts IC Documents
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.