Information Collection

Claimant's Statement

IC 122128 under ICR 198402-1215-002 · OMB 1215-0089.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

CLAIMANT'S STATEMENT

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	LS-267,203,	No	No
Form	204, 260,	No	No
Form	262, & 263	No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	137,935	-28	-18,737	156,700
Annual IC Time Burden (Hours)	64,304	-45	-29,701	94,050
Annual IC Cost Burden (Dollars)	0	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.