Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor

Documents and Forms

Document Name Document Type
Form CM-972 Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor Form
Form CM-972 Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor Form
CM-972 APPLICATION FOR APPROVAL OF A REPRESENTATIVE’S FEE IN A CM-972 Form.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-972 APPLICATION FOR APPROVAL OF A REPRESENTATIVE’S FEE IN A CM-972 Form.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor	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 725.366 20 CFR 725.365

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-972	APPLICATION FOR APPROVAL OF A REPRESENTATIVE’S FEE IN A BLACK LUNG CLAIM PROCEEDING CONDUCTED BY THE U.S. DEPARTMENT OF LABOR	CM-972 Form.docx	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title: DOL/OWCP-2	FR Citation: 81 FR 25858

Number of Respondents: 590	Number of Respondents for Small Entity: 276

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

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Previously Approved
Annual Number of Responses for this IC	590	590
Annual IC Time Burden (Hours)	413	413
Annual IC Cost Burden (Dollars)	204	204

Documents for IC

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