Information Collection

Notice of Payments

IC 13642 under ICR 201712-1240-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Payments	Form and Instruction
ls-208 Notice of Payments ls-208 NEW Proposed (2).pdf www.dol.gov/owcp/dlhwc/ls-208.pdf	Form and Instruction
DLHWC Seaportal.pdf DLHWC SEA Portal	IC Document

IC Title:

Notice of Payments

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 702.234 20 CFR 702.235

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 and Instruction	ls-208	Notice of Payments	ls-208 NEW Proposed (2).pdf	https://www.dol.gov/owcp/dlhwc/ls-208.pdf	Yes	Yes	Fillable Fileable

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	37,800	16,800	21,000
Annual IC Time Burden (Hours)	6,300	1,050	5,250
Annual IC Cost Burden (Dollars)	16,112	6,612	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.