MEDICARE PART B CERTIFICATION

ICR 198308-3206-001

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
156653 Migrated
ICR Details
3206-0017 198308-3206-001
Historical Active 198110-3206-022
OPM
MEDICARE PART B CERTIFICATION
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 09/28/1983
Retrieve Notice of Action (NOA) 08/01/1983
  Inventory as of this Action Requested Previously Approved
09/30/1986 09/30/1986
300 0 0
50 0 0
0 0 0

THIS FORM IS USED TO DETERMINE ELIGIBILITY FOR A GOVERNMENT CONTRIBUTION TOWARDS PART B OF MEDICARE FOR ANNUITANTS AND SURVIVOR ANNUITANTS UNDER THE RETIRED FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM.

None
None


No

1
IC Title Form No. Form Name
MEDICARE PART B CERTIFICATION 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 0 0 300 0 0
Annual Time Burden (Hours) 50 0 0 50 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
08/01/1983


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