Information Collection

Application For Reimbursement From Accured Amounts Due A Deceased Beneficiary

IC 147613 under ICR 198305-2900-002 · OMB 2900-0216.

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Documents and Forms

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Document Name	Document Type

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IC Title:

APPLICATION FOR REIMBURSEMENT FROM ACCURED AMOUNTS DUE A DECEASED BENEFICIARY

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	21-601				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,750

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,750	-3,750	7,500
Annual IC Time Burden (Hours)	1,875	-1,875	3,750
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.