Report of Changes That May Affect Your Black Lung Benefits

ICR 201105-1240-005

OMB: 1240-0028

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
2011-07-27
Supplementary Document
2011-06-09
Supplementary Document
2011-07-27
Supplementary Document
2008-03-12
Supplementary Document
2008-03-12
IC Document Collections
ICR Details
1240-0028 201105-1240-005
Historical Active 201003-1240-028
DOL/OWCP
Report of Changes That May Affect Your Black Lung Benefits
Extension without change of a currently approved collection   No
Regular
Approved without change 09/05/2011
Retrieve Notice of Action (NOA) 06/20/2011
  Inventory as of this Action Requested Previously Approved
09/30/2014 36 Months From Approved 09/30/2011
55,000 0 70,000
12,627 0 15,269
0 0 0

This information collection is necessary to help determine continuing eligibility of primary beneficiaries receiving black lung benefits from the Disability Trust Fund. It is also necessary to verify and update on a regular basis factors that affect a beneficiary's entitlement to benefits, including income, marital status, receipt of State Worker's Compensation, and dependent status.

US Code: 30 USC 936 Name of Law: Federal Mine Safety and Health Act
  
None

Not associated with rulemaking

  76 FR 13669 03/14/2011
76 FR 35914 06/20/2011
No

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 55,000 70,000 0 0 -15,000 0
Annual Time Burden (Hours) 12,627 15,269 0 0 -2,642 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
The total burden hours have decreased by 2,642 hours, from 15,269 to 12,627. This adjustment reflects a declining population of both Part C and Part B beneficiaries.

$366,382
No
No
No
No
No
Uncollected
Michael McClaran 202-693-0978 mcclaran.michael@dol.gov

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (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;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
06/20/2011


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