CONTRACTOR INFORMATION COLLECTION - FORGED CHECK INVESTIGATION FORMS

ICR 198310-0938-014

OMB: 0938-0205

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0205 198310-0938-014
Historical Active 198111-0938-009
HHS/CMS
CONTRACTOR INFORMATION COLLECTION - FORGED CHECK INVESTIGATION FORMS
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 11/10/1983
Retrieve Notice of Action (NOA) 10/31/1983
  Inventory as of this Action Requested Previously Approved
12/31/1984 12/31/1984
800 0 0
800 0 0
0 0 0

HCFA'S REGIONAL OFFICES, INTERMEDIARIES, OR CARRIERS INVESTIGATE REPORTS OF FORGED MEDICARE CHECKS. THESE FORMS GATHER INFORMATION FROM THE BENEFICIARY, BANK, AND CASHER OF THE CHECK.

None
None


No

1
IC Title Form No. Form Name
CONTRACTOR INFORMATION COLLECTION - FORGED CHECK INVESTIGATION FORMS 9014

  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 800 0 0 0 800 0
Annual Time Burden (Hours) 800 0 0 0 800 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.
10/31/1983


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