Paperwork Reduction Act Submission

PAPERWORK REDUCTION ACT SUBMISSION
Please read the instructions before completing this form. For additional forms or assistance in completing this form, contact your
agency's Paperwork Clearance Officer. Send two copies of this form, the collection instrument to be reviewed, the Supporting
Statement, and any additional documentation to: Office of Information and Regulatory Affairs, Office of Management and Budget,
Docket Library, Room 10102, 725 17th Street NW, Washington, DC 20503.
2. OMB CONTROL NUMBER

1. AGENCY/SUBAGENCY ORIGINATING REQUEST

DOL/ESA/OWCP/DCMWC
a.

4. TYPE OF REVIEW REQUESTED (X one)

3. TYPE OF INFORMATION COLLECTION (X one)
(For b. - f., note Item A2 of Supporting Statement instructions)

X

a. NEW COLLECTION

X

b. NONE

0034

1215

a. REGULAR SUBMISSION
b. EMERGENCY - APPROVAL REQUESTED BY:

b. REVISION OF A CURRENTLY APPROVED COLLECTION

c. DELEGATED

c. EXTENSION OF A CURRENTLY APPROVED COLLECTION
d. REINSTATEMENT, WITHOUT CHANGE, OF A PREVIOUSLY
APPROVED COLLECTION FOR WHICH APPROVAL HAS EXPIRED

5. SMALL ENTITIES
Will this information collection have a significant economic
impact on a substantial number of small entities?

e. REINSTATEMENT, WITH CHANGE, OF A PREVIOUSLY
APPROVED COLLECTION FOR WHICH APPROVAL HAS EXPIRED

6. REQUESTED EXPIRATION DATE

YES

NO

a. THREE YEARS FROM APPROVAL DATE

f. EXISTING COLLECTION IN USE WITHOUT AN OMB CONTROL
NUMBER

b. OTHER:

7. TITLE

Agreement and Undertaking
8. AGENCY FORM NUMBER(S) (if applicable)

OWCP-1
9. KEYWORDS

Black lung benefits, securities, compensation claims
10. ABSTRACT

The OWCP-1 is completed by coal mine operators to provide the Secretary of Labor with authorization to sell securities or to
bring suit under indemnity bonds deposited by the self-insured operators in the event there is a default in the payment of benefits.
12. OBLIGATION TO RESPOND (X one)

11. AFFECTED PUBLIC (Mark primary with "P" and all others that apply with "X")

P

a. VOLUNTARY

a. INDIVIDUALS OR HOUSEHOLDS

d. FARMS

b. BUSINESS OR OTHER FOR-PROFIT

e. FEDERAL GOVERNMENT

c. NOT-FOR-PROFIT INSTITUTIONS

f. STATE, LOCAL OR TRIBAL GOVERNMENT

13. ANNUAL REPORTING AND RECORDKEEPING HOUR BURDEN
a. NUMBER OF RESPONDENTS
b. TOTAL ANNUAL RESPONSES
(1) Percentage of these responses collected electronically
c. TOTAL ANNUAL HOURS REQUESTED
d. CURRENT OMB INVENTORY
e. DIFFERENCE (+, -)
f.

EXPLANATION OF
DIFFERENCE:

(1) Program change (+, -)
(2) Adustment (+, -)

20
20
0.00
5
75
-70
-50
-20

15. PURPOSE OF INFORMATION COLLECTION (Mark primary with

b. REQUIRED TO OBTAIN OR RETAIN BENEFITS

a. TOTAL CAPITAL/STARTUP COSTS
b. TOTAL ANNUAL COSTS (O&M)
c. TOTAL ANNUALIZED COST REQUESTED
d. CURRENT OMB INVENTORY
e. DIFFERENCE (+, -)
f.

e. PROGRAM PLANNING
OR MANAGEMENT

b. PROGRAM EVALUATION
c. GENERAL PURPOSE STATISTICS

P

17. STATISTICAL METHODS
Does this information collection employ
statistical methods?

OMB FORM 83-I, 10/95

X

NO

EXPLANATION OF DIFFERENCE:
(1) Program change (+, -)
(2) Adustment (+, -)

16. FREQUENCY OF RECORDKEEPING OR REPORTING (X all that apply)
a. RECORDKEEPING

a. APPLICATION FOR BENEFITS

YES

c. MANDATORY

14. ANNUALIZED COST TO RESPONDENTS (In thousands of dollars)

"P" and all others that apply with "X")

d. AUDIT

X

X

b. THIRD PARTY DISCLOSURE

c. REPORTING:

f. RESEARCH
g. REGULATORY OR
COMPLIANCE

X

(1) On Occasion

(2) Weekly

(3) Monthly

(4) Quarterly

(5) Semi-Annually

(6) Annually

(7) Biennially

(8) Other (Describe)

18. AGENCY CONTACT (Person who can best answer questions regarding the content of this
submission)
a. NAME (Last, First, Middle Initial)

Michael McClaran

b. TELEPHONE NUMBER (Include
area code)

(202) 693-0978

OMB CONTROL NUMBER

1215

TITLE

0034

Agreement and Undertaking

19. CERTIFICATION FOR PAPERWORK REDUCTION ACT SUBMISSIONS
a. PROGRAM OFFICIAL CERTIFICATION
(1) Signature

(2) Date

On behalf of this Federal agency, I certify that the collection of information encompassed by this request
complies with 5 CFR 1320.9.
NOTE: The text of 5 CFR 1320.9, and the related provisions of 5 CFR 1320.8(b)(3), appear at the end of the
instructions. The certification is to be made with reference to those regulatory provisions as set forth in the
instructions.
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 (see note in Item 19 of the instructions);
(i) If applicable, it uses effective and efficient statistical survey methodology; and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item below and explain the
reason in Item 18 of the Supporting Statement.

b. SENIOR OFFICIAL OR DESIGNEE CERTIFICATION
(1) Signature

OMB FORM 83-I (BACK), 10/95

(2) Date