Information Collection

Request for Earnings Information

IC 13778 under ICR 202409-1240-004 · OMB 1240-0025.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form LS-426 Request for Earnings Information	Form and Instruction
Form LS-426 Report for Earnings Information Request for Earnings Information	Form and Instruction
LS-426 Report for Earnings Information ls-426 (002).pdf www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-426.pdf	Form and Instruction
LS-426 Report for Earnings Information ls-426 (002).pdf www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-426.pdf	Form and Instruction
DLHWC SEAPortal 2024.pdf DLHWC SEA Portal	IC Document
DLHWC SEAPortal 2024.pdf DLHWC SEA Portal	IC Document

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:

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 and Instruction	LS-426			https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-426.pdf	Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: DOL/OWCP-3

FR Citation: 89 FR 71935

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 97 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	100	0	100
Annual IC Time Burden (Hours)	25	0	25
Annual IC Cost Burden (Dollars)	3	1	2

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
DLHWC SEA Portal		12/26/2024

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

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