Report of Changes That May Affect Your Black Lung Benefits

ICR 201405-1240-006

OMB: 1240-0028

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supplementary Document
2014-08-01
Supporting Statement A
2014-07-31
Supplementary Document
2014-08-01
IC Document Collections
ICR Details
1240-0028 201405-1240-006
Historical Active 201306-1240-007
DOL/OWCP
Report of Changes That May Affect Your Black Lung Benefits
Revision of a currently approved collection   No
Regular
Approved without change 12/23/2014
Retrieve Notice of Action (NOA) 09/25/2014
  Inventory as of this Action Requested Previously Approved
12/31/2017 36 Months From Approved 12/31/2014
35,030 0 55,000
7,118 0 12,627
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

  79 FR 28557 05/16/2014
79 FR 57578 09/25/2014
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 35,030 55,000 0 0 -19,970 0
Annual Time Burden (Hours) 7,118 12,627 0 0 -5,509 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
The total burden hours have decreased by 5,509 hours, from 12,627 to 7,118. This adjustment reflects a declining population of both Part C and Part B beneficiaries. There has been an enlargement of mailing cost due to postage increase. Minor changes have been made to CM-929 and CM-929P to provide clearer language so claimants can better understand what information they need to provide. Finally, an accommodation statement was placed on the form to inform claimants who have mental or physical limitations to contact DCMWC for if further assistance is needed in the claims process.

$254,084
No
No
No
No
No
Uncollected
Debbie Thurston 202 693-0913 Thurston.Debra@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.
09/25/2014


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