Customer Service Intake Form

Request for Assistance from the Department of Labor, Employee Benefits Security Administration

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0146 can be found here:

Documents and Forms

Document Name Document Type
Form 301 Customer Service Intake Form Form and Instruction
Request for Assistance Privacy Act and PRA Notices Screenshots (English).pdf www.askebsa.dol.gov/WebIntake/Home.aspx Other-Web Screenshots of Privacy Act
Request for Assistance Privacy Act and PRA Notices Screenshots (Spanish).pdf www.askebsa.dol.gov/WebIntake/Home.aspx?l=es Other-Web Screenshots of Privacy Act
301 Request for Assistance from Department of Labor, EBSA (E Request for Assistance Paper Option (English).pdf www.askebsa.dol.gov/WebIntake/Home.aspx Form and Instruction
301 Request for Assistance from Department of Labor, EBSA (S Request for Assistance Paper Option (Spanish).pdf www.askebsa.dol.gov/WebIntake/Home.aspx?l=es Form and Instruction
301 Request for Assistance from Department of Labor, EBSA (E Request for Assistance Web Option Screenshots (English).pdf www.askebsa.dol.gov/WebIntake/Home.aspx Form and Instruction
301 Request for Assistance from Department of Labor, EBSA (S Request for Assistance Web Option Screenshots (Spanish).pdf www.askebsa.dol.gov/WebIntake/Home.aspx?l=es Form and Instruction

Information Collection (IC) Details

IC Title:	Customer Service Intake Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	301	Request for Assistance from Department of Labor, EBSA (English Paper Version)	Request for Assistance Paper Option (English).pdf	https://www.askebsa.dol.gov/WebIntake/Home.aspx	Yes	Yes	Fillable Fileable
Form and Instruction	301	Request for Assistance from Department of Labor, EBSA (Spanish Paper Version)	Request for Assistance Paper Option (Spanish).pdf	https://www.askebsa.dol.gov/WebIntake/Home.aspx?l=es	Yes	Yes	Fillable Fileable
Other-Web Screenshots of Privacy Act and PRA Notices (English)			Request for Assistance Privacy Act and PRA Notices Screenshots (English).pdf	https://www.askebsa.dol.gov/WebIntake/Home.aspx	Yes	Yes	Fillable Fileable
Other-Web Screenshots of Privacy Act and PRA Notices (Spanish)			Request for Assistance Privacy Act and PRA Notices Screenshots (Spanish).pdf	https://www.askebsa.dol.gov/WebIntake/Home.aspx?l=es	Yes	Yes	Fillable Fileable
Form and Instruction	301	Request for Assistance from Department of Labor, EBSA (English Web Option Screenshots)	Request for Assistance Web Option Screenshots (English).pdf	https://www.askebsa.dol.gov/WebIntake/Home.aspx	Yes	Yes	Fillable Fileable
Form and Instruction	301	Request for Assistance from Department of Labor, EBSA (Spanish Web Option Screenshots)	Request for Assistance Web Option Screenshots (Spanish).pdf	https://www.askebsa.dol.gov/WebIntake/Home.aspx?l=es	Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: Technical Assistance and Inquiry Files, DOL/PWBA4	FR Citation: 67 FR 16816

Number of Respondents: 6,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	6,500	-23,500	30,000
Annual IC Time Burden (Hours)	3,250	-11,750	15,000
Annual IC Cost Burden (Dollars)	0	-3,100	3,100

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.