MEDICARE PART B CERTIFICATION CARD

ICR 198110-3206-022

OMB: 3206-0017

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
176560 Migrated
ICR Details
3206-0017 198110-3206-022
Historical Active 197805-3206-005
OPM
MEDICARE PART B CERTIFICATION CARD
No material or nonsubstantive change to a currently approved collection   No
Emergency 10/01/1981
Approved with change 10/01/1981
Retrieve Notice of Action (NOA) 10/01/1981
  Inventory as of this Action Requested Previously Approved
06/30/1983 06/30/1983 06/30/1983
300 0 650
50 0 108
0 0 0

THE FORM IS NECESSARY TO CERTIFY THAT CERTAIN ANNUITANTS OR SURVIVOR ANNUITANTS ARE ELIGIBLE FOR A GOVERNMENT CONTRIBUTION TOWARD THEIR PREMIUM FOR PART B OF MEDICARE AS PROVIDED BY P.L. 91-418. THE RFEHB PROGRAM AFFECTS CERTAIN ANNUITANTS AND THEIR SURVIVORS WHO RETIRED BEFORE JULY 1, 1960.

None
None


No

1
IC Title Form No. Form Name
MEDICARE PART B CERTIFICATION CARD SF2814-A

  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 300 650 0 -350 0 0
Annual Time Burden (Hours) 50 108 0 -58 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes

$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.
10/01/1981


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