REQUEST FOR TERMINATION OF SUPPLEMENTARY MEDICAL INSURANCE

ICR 198012-3220-002

OMB: 3220-0098

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
3220-0098 198012-3220-002
Historical Active 198009-3220-015
RRB
REQUEST FOR TERMINATION OF SUPPLEMENTARY MEDICAL INSURANCE
No material or nonsubstantive change to a currently approved collection   No
Emergency 12/26/1980
Approved with change 12/26/1980
Retrieve Notice of Action (NOA) 12/26/1980
  Inventory as of this Action Requested Previously Approved
01/31/1981 01/31/1981 12/31/1980
500 0 500
42 0 42
0 0 0

THE BOARD ADMINISTERS THE MEDICARE PROGRAM FOR PERSONS COVERED BY THE RAILROAD RETIREMENT SYSTEM. THE REQUEST WILL OBTAIN THE INFORMATION NEEDED BY THE BOARD TO TERMINATE AN INDIVIDUAL'S SUPPLEMENTARY MEDICAL INSURANCE UNDER THE PROGRAM.

None
None


No

1
IC Title Form No. Form Name
REQUEST FOR TERMINATION OF SUPPLEMENTARY MEDICAL INSURANCE G-718

  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 500 500 0 0 0 0
Annual Time Burden (Hours) 42 42 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.
12/26/1980


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