View Information Collection (IC)

View Information Collection (IC)

IC Title:	Statement of Recovery	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 10.707 (e) 20 CFR 10.710

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	ca-1122	Statement of Recovery	CA-1122 working.pdf	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: General Government

Subfunction: Central Personnel

Privacy Act System of Records
Title: DOL/GOVT-1 (Office of Worker's Compensation Programs, Federal Employees' Compemsation Act File	FR Citation: 67 FR 16827

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	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	10	0	0	-273	0	283
Annual IC Time Burden (Hours)	3	0	0	-68	0	71
Annual IC Cost Burden (Dollars)	3	0	0	-133	0	136

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.