Request for Assistance from the Department of Labor, Employee Benefits Security Administration

Forms and Documents

Document Name	Status
Form 301 Customer Service Intake Form Form and Instruction	Unchanged
1210-0146 Online inquiry form nonsubstantive change July 2022 Final.docx Justification for No Material/Nonsubstantive Change	2022-07-15
page 4 Screenshot 2022-07-15 100647.png Supplementary Document	2022-07-15
inquiry form page 3 part 2 Screenshot 2022-07-15 100406.png Supplementary Document	2022-07-15
inquiry form page 3 Screenshot 2022-07-15 100047.png Supplementary Document	2022-07-15
inquiry form page 2 part 2 Screenshot 2022-07-15 095841.png Supplementary Document	2022-07-15
inquiry form page 2 Screenshot 2022-07-15 095245.png Supplementary Document	2022-07-15
ask-ebsa-form-mock-up.png Supplementary Document	2022-07-13
30-day FRN (1210-0146) published.pdf Supplementary Document	2021-01-14
29 U.S. Code § 1134 - Investigative authority.pdf Supplementary Document	2021-01-07
29 U.S. Code § 1143 - Research, studies, and reports _ U.S. Code _ US Law _ LII _ Legal Information Institute.pdf Supplementary Document	2021-01-07
60-day FRN (1210-0146) published.pdf Supplementary Document	2021-01-07
Supporting Statement Web Intake Form 2020 (clean) 1.7.21.docx Supporting Statement A	2021-01-07

IC Document Collections

IC ID	Document Title	Status
198333	Customer Service Intake Form Form and Instruction	Unchanged

ICR Details

OMB Control No: 1210-0146	ICR Reference No: 202207-1210-002
Status: Received in OIRA	Previous ICR Reference No: 202011-1210-003
Agency/Subagency: DOL/EBSA	Agency Tracking No:
Title: Request for Assistance from the Department of Labor, Employee Benefits Security Administration
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 07/18/2022

	Requested	Previously Approved
Expiration Date	03/31/2024	03/31/2024
Responses	5,582	5,582
Time Burden (Hours)	2,791	2,791
Cost Burden (Dollars)	0	0

---

Abstract: EBSA assists participants in understanding their rights, responsibilities, and benefits under employee benefit law and intervenes informally on their behalf with the plan sponsor in order to assist them in obtaining the health and retirement benefits to which they may have been inappropriately denied, which can avert the necessity for a formal investigation or a civil action. EBSA has made a request for assistance form available on its Web site for those wishing to obtain assistance in this manner.

---

Authorizing Statute(s): US Code: 29 USC 1143 Name of Law: ERISA Section 513
   US Code: 29 USC 1134 Name of Law: ERISA Section 504
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 66580	10/20/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 3204	01/14/2021
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Customer Service Intake Form	301, 301, 301, 301	Request for Assistance from Department of Labor, EBSA (English Paper Version) ,   Request for Assistance from Department of Labor, EBSA (Spanish Paper Version) ,   Request for Assistance from Department of Labor, EBSA (English Web Option Screenshots) ,   Request for Assistance from Department of Labor, EBSA (Spanish Web Option Screenshots)

---

ICR Summary of Burden

	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	5,582	5,582	0	0	0	0
Annual Time Burden (Hours)	2,791	2,791	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The hour burden and monetized equivalent cost has been adjusted to reflect updated information on the number of web requests and labor costs.

---

Annual Cost to Federal Government: $1,500

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 07/18/2022

---