Information Collection Request
Application for Self-Insurance Under the Black Lung Benefits Act
ICR 202301-1240-004 · OMB 1240-0057 · Received in OIRA
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 1240-0057 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form CM-2017b Application for Self-Insurance Under the Black Lung Benefits Act |
Form | Modified | Repair queued |
 Supporting Statement 1240-0057 - Final-OCIO (2)MM.docx |
Supporting Statement A | Uploaded 2023-01-18 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 234819 |  Application for Self-Insurance Under the Black Lung Benefits Act |
Form | Modified |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | DOL/OWCP |
| OMB Control No | 1240-0057 |
| Type of Information Collection | Revision of a currently approved collection |
| Previous ICR Reference No | 202201-1240-003 |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |