STATEMENT OF PERSON REQUESTING PAYMENT ON BEHALF OF ESTATE

ICR 197807-0960-001

OMB: 0960-0048

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
0960-0048 197807-0960-001
Historical Active 197506-0960-001
SSA
STATEMENT OF PERSON REQUESTING PAYMENT ON BEHALF OF ESTATE
Extension without change of a currently approved collection   No
Regular
Approved without change 08/15/1978
Retrieve Notice of Action (NOA) 07/28/1978
  Inventory as of this Action Requested Previously Approved
07/31/1983 07/31/1983 06/30/1980
20,000 0 20,000
3,333 0 3,333
0 0 0

SECTION 202(I) OF THE SOCIAL SECURITY ACT PROVIDES FOR THE PAYMENT OF LUMP-SUM DEATH BENEFITS TO INDIVIDUALS WHO QUALIFY. THIS FORM IS USED BY PERSONS REQUESTING THE LUMP-SUM DEATH PAYMENT ON BEHALF OF A NONADMINISTERED ESTATE.

None
None


No

1
IC Title Form No. Form Name
STATEMENT OF PERSON REQUESTING PAYMENT ON BEHALF OF ESTATE SSA-717

  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 20,000 20,000 0 0 0 0
Annual Time Burden (Hours) 3,333 3,333 0 0 0 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.
07/28/1978


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