Certification of Funeral Expenses

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

Documents and Forms

Document Name Document Type
Form LS-265 Certification of Funeral Expenses Form
LS-265 Certification of Funeral Expenses LS-265.pdf www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-265.pdf Form
LS-265 Certification of Funeral Expenses LS-265.pdf www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-265.pdf Form
DLHWC Seaportal.pdf DLHWC SEA Portal IC Document
DLHWC Seaportal.pdf DLHWC SEA Portal IC Document

Information Collection (IC) Details

IC Title:	Certification of Funeral Expenses	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 702.121

Information Collection Instruments:

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

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/OWCP-3	FR Citation: 88 FR 30346

Number of Respondents: 75	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	75	0	75
Annual IC Time Burden (Hours)	19	0	19
Annual IC Cost Burden (Dollars)	26	25	1

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.