Information Collection

Application for Continuation of Death Benefit for Student

IC 13739 under ICR 202012-1240-002 · OMB 1240-0026.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0026 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form LS-266 Application for Continuation of Death Benefit for Student	Form and Instruction
LS-266 Application for Continuation of Death Benefit for Studen ls-266.pdf www/dol.gov/owcp/dlhwc/ls-266	Form and Instruction
LS-266 Application for Continuation of Death Benefit for Studen ls-266.pdf www/dol.gov/owcp/dlhwc/ls-266	Form and Instruction
DLHWC Seaportal.pdf DLHWC SEA Portal	IC Document
DLHWC Seaportal.pdf DLHWC SEA Portal	IC Document

IC Title:

Application for Continuation of Death Benefit for Student

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 702.121

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-266	Application for Continuation of Death Benefit for Student under the LHWCA	ls-266.pdf	https://www/dol.gov/owcp/dlhwc/ls-266	Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: DOL/OWCP-3

FR Citation: 67 FR 16870

Number of Respondents: 20

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	20	0	20
Annual IC Time Burden (Hours)	10	0	10
Annual IC Cost Burden (Dollars)	0	-6	6

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.