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Certification of Funeral Expenses
Certification of Funeral Expenses
OMB: 1215-0027
IC ID: 13646
OMB.report
DOL/ESA
OMB 1215-0027
ICR 200709-1215-005
IC 13646
( )
Documents and Forms
Document Name
Document Type
Form LS-265
Certification of Funeral Expenses
Form
LS-265 Certification of Funeral Expenses
ls-265.pdf
www.dol.gov/esa/owcp/dlhwc/ls-265.pdf
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Certification of Funeral Expenses
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 702.121
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
LS-265
Certification of Funeral Expenses
ls-265.pdf
http://www.dol.gov/esa/owcp/dlhwc/ls-265.pdf
Yes
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Workforce Management
Subfunction:
Worker Safety
Privacy Act System of Records
Title:
DOL/GOVT-15
FR Citation:
58 FR 49599
Number of Respondents:
195
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
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
195
0
0
0
0
195
Annual IC Time Burden (Hours)
49
0
0
0
0
49
Annual IC Cost Burden (Dollars)
86
0
0
86
0
0
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.