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

OMB 1210-0146

EBSA assists participants in understanding their rights, responsibilities, and benefits under employee benefit law and intervenes informally on their behalf with the plan sponsor in order to assist them in obtaining the health and retirement benefits to which they may have been inappropriately denied, which can avert the necessity for a formal investigation or a civil action. EBSA has made a request for assistance form available on its Web site for those wishing to obtain assistance in this manner.

The latest form for Request for Assistance from the Department of Labor, Employee Benefits Security Administration expires 2021-01-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 301 Customer Service Intake Form Form and Instruction
1210-0146 Supporting Statement Web Intake Form 02-09-24.docx Supporting Statement A
Justification for No Material or Nonsubstantive Change to Currently Approved Collection (OMB Control 1210-0146)_9.10.24 (clean).docx Justification for No Material/Nonsubstantive Change
page 4 Screenshot 2022-07-15 100647.png Supplementary Document
inquiry form page 3 part 2 Screenshot 2022-07-15 100406.png Supplementary Document
inquiry form page 3 Screenshot 2022-07-15 100047.png Supplementary Document
inquiry form page 2 part 2 Screenshot 2022-07-15 095841.png Supplementary Document
inquiry form page 2 Screenshot 2022-07-15 095245.png Supplementary Document
ask-ebsa-form-mock-up.png Supplementary Document
30-day FRN (1210-0146) published.pdf Supplementary Document
29 U.S. Code § 1134 - Investigative authority.pdf Supplementary Document
29 U.S. Code § 1143 - Research, studies, and reports _ U.S. Code _ US Law _ LII _ Legal Information Institute.pdf Supplementary Document
60-day FRN (1210-0146) published.pdf Supplementary Document
Customer Service Intake Form Form and Instruction

All Historical Document Collections

202409-1210-003 Approved without change	No material or nonsubstantive change to a currently approved collection	2024-09-10
202401-1210-003 Approved without change	Extension without change of a currently approved collection	2024-02-23
202207-1210-002 Approved without change	No material or nonsubstantive change to a currently approved collection	2022-07-18
202011-1210-003 Approved without change	Extension without change of a currently approved collection	2021-01-14
201708-1210-002 Approved without change	Extension without change of a currently approved collection	2017-10-30
201407-1210-002 Approved without change	Extension without change of a currently approved collection	2014-09-24
201106-1210-001 Approved without change	New collection (Request for a new OMB Control Number)	2011-08-04