Notice of Payments

Notice of Final Payment or Suspension of Compensation Benefits

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.