Information Collection

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

IC 13877 under ICR 202401-1240-007 · OMB 1240-0011.

Documents and Forms

Documents and forms in this information collection
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
Form CM-972 APPLICATION FOR APPROVAL OF A REPRESENTATIVE’S FEE IN A BLACK LUNG CLAIM PROCEEDING CONDUCTED BY THE U.S. DEPARTMENT OF LABOR 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 CM-972 Form.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Form
CM-972 APPLICATION FOR APPROVAL OF A REPRESENTATIVE’S FEE IN A CM-972 Form.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Form

IC Title:

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 725.366 20 CFR 725.365

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	CM-972			https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	590	590
Annual IC Time Burden (Hours)	413	413
Annual IC Cost Burden (Dollars)	204	204

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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