Information Collection Request
Application for Self-Insurance Under the Black Lung Benefits Act
ICR 202401-1240-005 · OMB 1240-0057 · Active
⚠️ Notice: This information collection may be outdated.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 |
|---|---|---|---|
 Supporting Statement 1240-0057 after comments.docx |
Supporting Statement A | Uploaded 2024-01-30 | Available |
| Supporting Statement 1240-0057 after comments.docx |
Supporting Statement A | Uploaded 2024-01-30 | Repair queued |
| Justification 1240-0057.docx |
Justification for No Material/Nonsubstantive Change | Uploaded 2024-01-30 | Available |
| Justification 1240-0057.docx |
Justification for No Material/Nonsubstantive Change | Uploaded 2024-01-30 | Repair queued |
| Response to comments submitted to OIRA .8.10.22.docx |
Supplementary Document | Uploaded 2022-09-07 | Available |
| Response to comments submitted to OIRA .8.10.22.docx |
Supplementary Document | Uploaded 2022-09-07 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 234819 |  Application for Self-Insurance Under the black Lung Benefits Act |
Instruction | Modified |
ICR Details
| Status | Active |
|---|---|
| Agency/Subagency | DOL/OWCP |
| OMB Control No | 1240-0057 |
| Type of Information Collection | No material or nonsubstantive change to a currently approved collection |
| Previous ICR Reference No | 202201-1240-003 |
| Date Submitted to OIRA | 2024-01-31 |
| Requested Expiration Date | 1969-12-31 |