Report of Changes That May Affect Your Black Lung Benefits

Forms and Documents

Document Name	Status
Form CM-929 Report of Changes That May Affect Your Black Lung Benefits Form and Instruction	Modified
Notice to Reviewer CM-929 and CM-929P 20150605.docx Justification for No Material/Nonsubstantive Change	2015-06-05
2014 Supporting Statement 1240-0028.doc Supporting Statement A	2015-05-27
30 USC 936.pdf Supplementary Document	2014-08-01
DOL Privacy Act systems ESA-6.pdf Supplementary Document	2014-08-01

IC Document Collections

IC ID	Document Title	Status
13756	Report of Changes That May Affect Your Black Lung Benefits Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0028	ICR Reference No: 201501-1240-002
Status: Historical Active	Previous ICR Reference No: 201405-1240-006
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Report of Changes That May Affect Your Black Lung Benefits
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/17/2015
	Date Received in OIRA: 06/05/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2017	12/31/2017	12/31/2017
Responses	35,030	0	35,030
Time Burden (Hours)	7,118	0	7,118
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): US Code: 30 USC 936 Name of Law: Federal Mine Safety and Health Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 28557	05/16/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 57578	09/25/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Report of Changes That May Affect Your Black Lung Benefits	CM-929, CM-929P	Report of Changes That May Affect Your Black Lung Benefits ,   Report of Changes That May Affect Your Black Lung Benefits

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ICR Summary of Burden

	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

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $254,084

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(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.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 06/05/2015

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