APPLICATION FOR MEDICAL INSURANCE

ICR 197903-0960-034

OMB: 0960-0092

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
166545 Migrated
ICR Details
0960-0092 197903-0960-034
Historical Active 197808-0960-005
SSA
APPLICATION FOR MEDICAL INSURANCE
No material or nonsubstantive change to a currently approved collection   No
Emergency 03/28/1979
Approved with change 03/28/1979
Retrieve Notice of Action (NOA) 03/28/1979
  Inventory as of this Action Requested Previously Approved
11/30/1980 11/30/1980 11/30/1980
90,000 0 90,000
9,000 0 9,000
0 0 0



None
None


No

1
IC Title Form No. Form Name
APPLICATION FOR MEDICAL INSURANCE SSA-4040

  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 90,000 90,000 0 0 0 0
Annual Time Burden (Hours) 9,000 9,000 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.
03/28/1979


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