Request for Earnings Information

Request for Earnings Information Report

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0025 can be found here:

Documents and Forms

Document Name Document Type
Form LS-426 Request for Earnings Information Form and Instruction
LS-426 Request for Earnings Information ls-426.pdf www.dol.gov/owcp/dlhwc/ls-426.pdf Form and Instruction
DLHWC Seaportal.pdf DLHWC SEA Portal IC Document

Information Collection (IC) Details

IC Title:	Request for Earnings Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	LS-426	Request for Earnings Information	ls-426.pdf	https://www.dol.gov/owcp/dlhwc/ls-426.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/ ESA-15	FR Citation: 67 FR 16886

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 13 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	100	0	100
Annual IC Time Burden (Hours)	25	0	25
Annual IC Cost Burden (Dollars)	23	-22	45

Documents for IC

Title	Document	Date Uploaded
DLHWC SEA Portal	DLHWC Seaportal.pdf	09/24/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.