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Survivor's Form for Benefits
Survivor's Form for Benefits
OMB: 1215-0069
IC ID: 13721
OMB.report
DOL/ESA
OMB 1215-0069
ICR 200703-1215-004
IC 13721
( )
Documents and Forms
Document Name
Document Type
Form CM-912
Survivor's Form for Benefits
Form
CM-912 Survivor's Form For Benefits Under The Black Lung Benefi
cm-912.pdf
www.dol.gov/esa/regs/compliance/owcp/cm-912.pdf
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Survivor's Form for Benefits
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 410.221
20 CFR 725.304
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CM-912
Survivor's Form For Benefits Under The Black Lung Benefits Act
cm-912.pdf
http://www.dol.gov/esa/regs/compliance/owcp/cm-912.pdf
Yes
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Income Security
Subfunction:
Survivor Compensation
Privacy Act System of Records
Title:
ESA-6 (67 FR 16869) and ESA-30 (67 FR 16878)
FR Citation:
67 FR 16869
Number of Respondents:
2,000
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
2,000
0
0
-800
0
2,800
Annual IC Time Burden (Hours)
267
0
0
-106
0
373
Annual IC Cost Burden (Dollars)
704
0
0
-296
0
1,000
Documents for IC
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.
