Report of Changes That May Affect Your Black Lung Benefits

ICR 201710-1240-003

OMB: 1240-0028

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supplementary Document
2017-11-22
Supplementary Document
2017-11-22
Supplementary Document
2017-11-22
Supplementary Document
2017-11-22
Supporting Statement A
2017-12-14
IC Document Collections
ICR Details
1240-0028 201710-1240-003
Active 201501-1240-002
DOL/OWCP
Report of Changes That May Affect Your Black Lung Benefits
Revision of a currently approved collection   No
Regular
Approved without change 02/16/2018
Retrieve Notice of Action (NOA) 12/31/2017
  Inventory as of this Action Requested Previously Approved
02/28/2021 36 Months From Approved 02/28/2018
26,000 0 35,030
6,089 0 7,118
0 0 0

This information collection is necessary to help determine continuing eligibility of primary beneficiaries receiving black lung benefits from the Disability Trust Fund. It is also necessary to verify and update on a regular basis factors that affect a beneficiary's entitlement to benefits, including income, marital status, receipt of State Worker's Compensation, and dependent status.

US Code: 30 USC 936 Name of Law: Federal Mine Safety and Health Act
  
None

Not associated with rulemaking

  82 FR 47773 10/13/2017
82 FR 154 12/31/2017
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 26,000 35,030 0 0 -9,030 0
Annual Time Burden (Hours) 6,089 7,118 0 0 -1,029 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
The total burden hours have decreased by 1,029 hours, from 7,118 to 6,089. This adjustment reflects a declining population of both Part C and Part B beneficiaries.

$174,678
No
    Yes
    Yes
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.
12/31/2017


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