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Request For Termination Of Supplementary Medical Insurance
REQUEST FOR TERMINATION OF SUPPLEMENTARY MEDICAL INSURANCE
OMB: 3220-0098
IC ID: 177116
OMB.report
RRB
OMB 3220-0098
ICR 198012-3220-002
IC 177116
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0098 can be found here:
1988-04-08 - No material or nonsubstantive change to a currently approved collection
1987-12-02 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
REQUEST FOR TERMINATION OF SUPPLEMENTARY MEDICAL INSURANCE
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Migrated
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
G-718
No
No
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
500
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
500
0
0
0
0
500
Annual IC Time Burden (Hours)
42
0
0
0
0
42
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.