Certification of Funeral Expenses under the Longshore and Harbor Workers' Compensation Act

OMB 1240-0040

Form LS-265 is used to report funeral expenses payable under the Longshore and Harbor Workers' Compensation Act.

The latest form for Certification of Funeral Expenses under the Longshore and Harbor Workers' Compensation Act expires 2023-10-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form LS-265 Certification of Funeral Expenses Form
Supporting Statement for 1240-0040 10-2023_MNclean.docx Supporting Statement A
2023 60-Day FRN_1240-0040.pdf Supplementary Document
PRIVACY ACT SYSTEMS - EFF. 2019.docx Supplementary Document
20CFR702.121.mht Supplementary Document
33 USC section 909.doc Supplementary Document
Certification of Funeral Expenses Form

All Historical Document Collections

202309-1240-005 Approved without change	Revision of a currently approved collection	2023-10-17
202012-1240-003	No material or nonsubstantive change to a currently approved collection	2020-12-15
202003-1240-007 Approved without change	Extension without change of a currently approved collection	2020-08-11
201703-1240-003 Approved without change	Extension without change of a currently approved collection	2017-05-18
201506-1240-008 Approved without change	Revision of a currently approved collection	2015-06-05
201412-1240-011 Preapproved	No material or nonsubstantive change to a currently approved collection	2015-03-12
201409-1240-010 Approved without change	No material or nonsubstantive change to a currently approved collection	2014-09-30
201312-1240-002 Approved without change	Extension without change of a currently approved collection	2014-04-10
201102-1240-001 Approved without change	Extension without change of a currently approved collection	2011-02-28
201003-1240-040 Approved without change	Extension without change of a currently approved collection	2010-03-12