Information Collection

Benefit Appeals Report -- Extended Benefits (ETA 5130)

IC 239600 under ICR 202603-1205-004 · OMB 1205-0172.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form ETA 5130 Benefit Appeals Report Benefit Appeals Report -- Extended Benefits (ETA 5130)	Form and Instruction
ETA 5130 Benefit Appeals Report DOL-ETA 1205-0172 - ETA 5130 - 07.12.23 OCIO2.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

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	ETA 5130				Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: Unemployment Compensation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 53

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	636	636
Annual IC Time Burden (Hours)	636	636
Annual IC Cost Burden (Dollars)	0	0

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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