Information Collection

Application For Coinsurance Benefits

IC 143884 under ICR 198104-2502-001 · OMB 2502-0134.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2502-0134 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	APPLICATION FOR COINSURANCE BENEFITS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	HUD 4035.1,	No	No
Form	4035.2,	No	No
Form	4035.3	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 18	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	18	18
Annual IC Time Burden (Hours)	22	22
Annual IC Cost Burden (Dollars)	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.