REQUEST FOR PAYMENT-MEDICAL INSURANCE BENEFITS FOR RR BENEFI CIARIES-SOCIAL SECURITY ACT

ICR 197611-3220-003

OMB: 3220-0085

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
3220-0085 197611-3220-003
Historical Active
RRB
REQUEST FOR PAYMENT-MEDICAL INSURANCE BENEFITS FOR RR BENEFI CIARIES-SOCIAL SECURITY ACT
Extension without change of a currently approved collection   No
Regular
Approved without change 11/18/1976
Retrieve Notice of Action (NOA) 11/09/1976
  Inventory as of this Action Requested Previously Approved
01/31/1981 01/31/1981
1,300,000 0 0
216,666 0 0
0 0 0



None
None


No

1
IC Title Form No. Form Name
REQUEST FOR PAYMENT-MEDICAL INSURANCE BENEFITS FOR RR BENEFI CIARIES-SOCIAL SECURITY ACT G-740

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 1,300,000 0 0 0 1,300,000 0
Annual Time Burden (Hours) 216,666 0 0 0 216,666 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
11/09/1976


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