APPLICATION FOR BENEFITS BY A MENTAL INSTITUTION ON BEHALF OF A PATIENT

ICR 198305-0960-006

OMB: 0960-0114

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
0960-0114 198305-0960-006
Historical Active 197809-0960-009
SSA
APPLICATION FOR BENEFITS BY A MENTAL INSTITUTION ON BEHALF OF A PATIENT
Revision of a currently approved collection   No
Regular
Approved without change 07/11/1983
Retrieve Notice of Action (NOA) 05/16/1983
  Inventory as of this Action Requested Previously Approved
07/31/1986 07/31/1986 08/31/1983
25,000 0 25,000
3,750 0 3,750
0 0 0

THE INFORMATION COLLECTED BY THE USE OF THIS FORM IS NEEDED TO DETERMI THE PATIENT'S ENTITLEMENT STATUS FOR DISABILITY BENEFITS. THE DATA ALS PROTECT THE PATIENT'S RIGHT TO BENEFITS AND CONSTITUTE A SKELETON APPLICATION IF ENTITLEMENT CAN BE ESTABLISHED.

None
None


No

1
IC Title Form No. Form Name
APPLICATION FOR BENEFITS BY A MENTAL INSTITUTION ON BEHALF OF A PATIENT SSA-2333, (5-83)

  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 25,000 25,000 0 0 0 0
Annual Time Burden (Hours) 3,750 3,750 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.
05/16/1983


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