Information Collection

Claims and Payment Activities

IC 12927 under ICR 202112-1205-007 · OMB 1205-0010.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1205-0010 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form ETA 5159 Claims and Payment Activities	Form and Instruction
Form ETA 5159 Claims and Payment Activities Claims and Payment Activities	Form and Instruction
ETA 5159 Claims and Payment Activities SectionI_ClaimantActivity_ETA 5159.docx	Form and Instruction
ETA 5159 Claims and Payment Activities SectionI_ClaimantActivity_ETA 5159.docx	Form and Instruction

IC Title:

Claims and Payment Activities

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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	ETA 5159				Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: Unemployment Compensation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 53

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,544	2,544
Annual IC Time Burden (Hours)	6,996	6,996
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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