Report of Changes That May Affect Your Black Lung Benefits

ICR 202101-1240-001

OMB: 1240-0028

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
2021-02-17
Supplementary Document
2021-02-12
Supplementary Document
2021-02-12
Supplementary Document
2021-01-07
Supplementary Document
2021-01-07
Supplementary Document
2021-01-07
Supplementary Document
2021-01-07
Supplementary Document
2017-11-22
IC Document Collections
ICR Details
1240-0028 202101-1240-001
Received in OIRA 201710-1240-003
DOL/OWCP
Report of Changes That May Affect Your Black Lung Benefits
Extension without change of a currently approved collection   No
Regular 02/17/2021
  Requested Previously Approved
36 Months From Approved 02/28/2021
12,000 26,000
2,810 6,089
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 901 Name of Law: Black Lung Benefits Act
  
None

Not associated with rulemaking

  85 FR 75049 11/24/2020
86 FR 9389 02/12/2021
No

  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 12,000 26,000 0 0 -14,000 0
Annual Time Burden (Hours) 2,810 6,089 0 0 -3,279 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
The total burden hours have decreased by 3,279 hours, from 6,089 to 2,810. This adjustment reflects a declining population of Part C beneficiaries. The option to submit the completed form online through the COAL Mine web portal was added to both forms.

$107,215
No
    Yes
    Yes
No
No
No
No
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.
02/17/2021


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