Application for Continuation of Death Benefit for Student

ICR 202012-1240-002

OMB: 1240-0026

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Justification for No Material/Nonsubstantive Change
2020-12-15
Supporting Statement A
2020-05-27
Supplementary Document
2013-11-12
Supplementary Document
2013-11-12
IC Document Collections
ICR Details
1240-0026 202012-1240-002
Received in OIRA 202001-1240-003
DOL/OWCP
Application for Continuation of Death Benefit for Student
No material or nonsubstantive change to a currently approved collection   No
Regular 12/15/2020
  Requested Previously Approved
10/31/2023 10/31/2023
20 20
10 10
0 6

Form LS-266 is used as an application for continuation of death benefits for a dependent who is a student.

US Code: 33 USC 902(18) Name of Law: The Longshore and Harbor Workers' Compensation Act
   US Code: 33 USC 939(a) Name of Law: The Longshore and Harbor Workers' Compensation Act
  
None

Not associated with rulemaking

  85 FR 15230 03/17/2020
85 FR 31229 05/22/2020
No

1
IC Title Form No. Form Name
Application for Continuation of Death Benefit for Student LS-266 Application for Continuation of Death Benefit for Student under the LHWCA

  Total Request 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 20 20 0 0 0 0
Annual Time Burden (Hours) 10 10 0 0 0 0
Annual Cost Burden (Dollars) 0 6 0 -6 0 0
No
No

$66,079
No
    Yes
    Yes
No
No
No
No
Cheryl Jordan 202 693-0289 [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.
12/15/2020


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