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Agreement and Undertaking
Agreement and Undertaking
OMB: 1240-0039
IC ID: 13662
OMB.report
DOL/OWCP
OMB 1240-0039
ICR 202401-1240-001
IC 13662
( )
Documents and Forms
Document Name
Document Type
Form OWCP-1
Agreement and Undertaking
Form
OWCP-1 Agreement and Undertaking
OWCP-1 Current form.pdf
www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black
Form
OWCP-1 Agreement and Undertaking
OWCP-1 Changed name.pdf
www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Agreement and Undertaking
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 726.110
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
OWCP-1
Agreement and Undertaking
OWCP-1 Changed name.pdf
https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black
Yes
Yes
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Income Security
Subfunction:
General Retirement and Disability
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
20
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
75 %
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
20
0
0
3
0
17
Annual IC Time Burden (Hours)
5
0
0
1
0
4
Annual IC Cost Burden (Dollars)
4
0
0
2
0
2
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
