View Information Collection (IC)

View Information Collection (IC)

IC Title:	Request for Earnings Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	LS-426	Request for Earnings Information	ls-426.pdf	http://www.dol.gov/owcp/dlhwc/ls-426.pdf	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/ ESA-15	FR Citation: 67 FR 16886

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 13 %

	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	100	0	0	-1,000	0	1,100
Annual IC Time Burden (Hours)	25	0	0	-250	0	275
Annual IC Cost Burden (Dollars)	45	0	0	-414	0	459

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.