Benefit Appeals Report

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form ETA 5130 Benefit Appeals Report	Form and Instruction	Unchanged	Available
Form ETA 5130 Benefit Appeals Report	Form and Instruction	Unchanged	Available
Comment on ETA5130 Benefit Appeals Report (OMB Control No 1205 0172).msg	Public Comments	Uploaded 2026-03-27	Available
Benefit Appeals Report _6.22.26.docx	Supporting Statement A	Uploaded 2026-06-22	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
239600	Benefit Appeals Report -- Extended Benefits (ETA 5130)	Form and Instruction	Unchanged	Benefit Appeals Report
13008	Benefit Appeals Report (ETA 5130 REG)	Form and Instruction	Unchanged	Benefit Appeals Report

ICR Details

OMB Control No: 1205-0172	ICR Reference No: 202603-1205-004
Status: Received in OIRA	Previous ICR Reference No: 202304-1205-005
Agency/Subagency: DOL/ETA	Agency Tracking No:
Title: Benefit Appeals Report
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 06/26/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	07/31/2026
Responses	1,272	1,272
Time Burden (Hours)	1,272	1,272
Cost Burden (Dollars)	0	0

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Abstract: The ETA 5130, Benefit Appeals Report, contains information on the number of appeals and the resultant decisions classified by program, appeal level, cases filed and disposed of (workload flow), and decisions by level, appellant and issue. The data on this form are used to monitor the benefit appeals process in the state workforce agencies (SWAs). Data are also used for budgeting and workload data.

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Authorizing Statute(s): US Code: 42 USC 503(a)(6) Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 3223	01/26/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 38736	06/26/2026
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Benefit Appeals Report (ETA 5130 REG)	ETA 5130	Benefit Appeals Report
Benefit Appeals Report -- Extended Benefits (ETA 5130)	ETA 5130	Benefit Appeals Report

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ICR Summary of Burden

table that charts list of burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,272	1,272	0	0	0	0
Annual Time Burden (Hours)	1,272	1,272	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $15,976

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/26/2026

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