Certification of Funeral Expenses

Certification of Funeral Expenses under the Longshore and Harbor Workers' Compensation Act

OMB: 1240-0040

IC ID: 13646

Information Collection (IC) Details

View Information Collection (IC)

Certification of Funeral Expenses
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 702.121

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form LS-265 Certification of Funeral Expenses LS-265.pdf https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-265.pdf Yes Yes Fillable Fileable

Income Security General Retirement and Disability

DOL/OWCP-3  88 FR 30346

75 0
   
Private Sector Businesses or other for-profits
 
   50 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 75 0 0 0 0 75
Annual IC Time Burden (Hours) 19 0 0 0 0 19
Annual IC Cost Burden (Dollars) 26 0 25 0 0 1

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.

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