Experience Rating Report

ICR 201506-1205-004

OMB: 1205-0164

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
2015-06-18
IC Document Collections
IC ID
Document
Title
Status
13005 Modified
ICR Details
1205-0164 201506-1205-004
Historical Active 201203-1205-002
DOL/ETA
Experience Rating Report
Extension without change of a currently approved collection   No
Regular
Approved without change 08/18/2015
Retrieve Notice of Action (NOA) 06/22/2015
  Inventory as of this Action Requested Previously Approved
08/31/2018 36 Months From Approved 08/31/2015
53 0 53
27 0 27
0 0 0

The ETA-204 provides data to ETA for the study of seasonality, employment or payroll fluctuations, and stabilization, expansion or contraction in operations on employment experience. The data are used to provide an indication of whether solvency problems exist in the State's Trust Fund accounts and in analyzing factors that give rise to solvency problems. The data are also used to complete the Experience Rating Index.

US Code: 42 USC 503(a)(6) Name of Law: Social Security Act
  
None

Not associated with rulemaking

  79 FR 70568 11/26/2014
80 FR 35677 06/22/2015
No

1
IC Title Form No. Form Name
Experience Rating Report ETA 204 Experience Rating Report

  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 53 53 0 0 0 0
Annual Time Burden (Hours) 27 27 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$26,367
No
No
No
No
No
Uncollected
Walter Parker 202 693-2778 parker.walter@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.
06/22/2015


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