Customer Service Intake Form

Request for Assistance from the Department of Labor, Employee Benefits Security Administration

OMB: 1210-0146

IC ID: 198333

Documents and Forms
Document Name
Document Type
Form and Instruction
Other-Web Screenshots of Privacy Act
Other-Web Screenshots of Privacy Act
Other-Web Screenshots of Privacy Act
Other-Web Screenshots of Privacy Act
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Customer Service Intake Form
 
No Unchanged
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 301 Request for Assistance from Department of Labor, EBSA (English Paper Version) Request for Assistance Paper Option (English).pdf https://www.askebsa.dol.gov/WebIntake/Home.aspx Yes Yes Fillable Fileable
Form and Instruction 301 Request for Assistance from Department of Labor, EBSA (Spanish Paper Version) Request for Assistance Paper Option (Spanish).pdf https://www.askebsa.dol.gov/WebIntake/Home.aspx?l=es Yes Yes Fillable Fileable
Other-Web Screenshots of Privacy Act and PRA Notices (English) Request for Assistance Privacy Act and PRA Notices Screenshots (English).pdf https://www.askebsa.dol.gov/WebIntake/Home.aspx Yes Yes Fillable Fileable
Other-Web Screenshots of Privacy Act and PRA Notices (Spanish) Request for Assistance Privacy Act and PRA Notices Screenshots (Spanish).pdf https://www.askebsa.dol.gov/WebIntake/Home.aspx?l=es Yes Yes Fillable Fileable
Form and Instruction 301 Request for Assistance from Department of Labor, EBSA (English Web Option Screenshots) Request for Assistance Web Option Screenshots (English).pdf https://www.askebsa.dol.gov/WebIntake/Home.aspx Yes Yes Fillable Fileable
Form and Instruction 301 Request for Assistance from Department of Labor, EBSA (Spanish Web Option Screenshots) Request for Assistance Web Option Screenshots (Spanish).pdf https://www.askebsa.dol.gov/WebIntake/Home.aspx?l=es Yes Yes Fillable Fileable

Income Security General Retirement and Disability

Technical Assistance and Inquiry Files, DOL/PWBA–4  67 FR 16816

14,991 11,573
   
Individuals or Households
 
   100 %

  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 14,991 0 0 0 0 14,991
Annual IC Time Burden (Hours) 7,496 0 0 0 0 7,496
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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