Report of Changes That May Affect Your Black Lung Benefits

ICR 201501-1240-002

OMB: 1240-0028

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Justification for No Material/Nonsubstantive Change
2015-06-05
Supporting Statement A
2015-05-27
Supplementary Document
2014-08-01
Supplementary Document
2014-08-01
IC Document Collections
ICR Details
1240-0028 201501-1240-002
Historical Active 201405-1240-006
DOL/OWCP
Report of Changes That May Affect Your Black Lung Benefits
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 06/17/2015
Retrieve Notice of Action (NOA) 06/05/2015
  Inventory as of this Action Requested Previously Approved
12/31/2017 12/31/2017 12/31/2017
35,030 0 35,030
7,118 0 7,118
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 35,030 0 0 0 0
Annual Time Burden (Hours) 7,118 7,118 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$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.
06/05/2015


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