Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0011 can be found here:

Documents and Forms

Document Name Document Type
Form CM-972 Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor Form
CM-972 APPLICATION FOR APPROVAL OF A REPRESENTATIVE’S FEE IN A Form Attorney Fee Application.docx www.dol.gov/sites/dolgov/files/owcp/regs/compliance/cm-972.pdf Form
CM-972 APPLICATION FOR APPROVAL OF A REPRESENTATIVE’S FEE IN A Updated Attorney Fee Application Form.docx www.dol.gov/sites/dolgov/files/owcp/regs/compliance/cm-972.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor	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 725.365 20 CFR 725.366

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CM-972	APPLICATION FOR APPROVAL OF A REPRESENTATIVE’S FEE IN A BLACK LUNG CLAIM PROCEEDING CONDUCTED BY THE U.S. DEPARTMENT OF LABOR	Updated Attorney Fee Application Form.docx	https://www.dol.gov/sites/dolgov/files/owcp/regs/compliance/cm-972.pdf	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title: DOL/OWCP-2	FR Citation: 81 FR 25858

Number of Respondents: 590	Number of Respondents for Small Entity: 276

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	590	-354	944
Annual IC Time Burden (Hours)	413	-248	661
Annual IC Cost Burden (Dollars)	204	-344	548

Documents for IC

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