APPLICATION FOR REIMBUSEMENT FOR HOSPITAL INSURANCE SERVICE FURNISHED IN CANADA

ICR 197908-3220-009

OMB: 3220-0086

Federal Form Document

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Document
Name
Status
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IC Document Collections
ICR Details
3220-0086 197908-3220-009
Historical Active 197907-3220-014
RRB
APPLICATION FOR REIMBUSEMENT FOR HOSPITAL INSURANCE SERVICE FURNISHED IN CANADA
Extension without change of a currently approved collection   No
Regular
Approved without change 09/27/1979
Retrieve Notice of Action (NOA) 08/31/1979
  Inventory as of this Action Requested Previously Approved
09/30/1980 09/30/1980 09/30/1979
600 0 600
100 0 100
0 0 0



None
None


No

1
IC Title Form No. Form Name
APPLICATION FOR REIMBUSEMENT FOR HOSPITAL INSURANCE SERVICE FURNISHED IN CANADA AA-104

  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 600 600 0 0 0 0
Annual Time Burden (Hours) 100 100 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.
08/31/1979


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