Information Collection

Request From Claimant For Information On Earnings, Dual Benefits, And Third Party Settlement

IC 122299 under ICR 198402-1215-003 · OMB 1215-0151.

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Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

REQUEST FROM CLAIMANT FOR INFORMATION ON EARNINGS, DUAL BENEFITS, AND THIRD PARTY SETTLEMENT

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	CA-1032				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 38,000

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	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	38,000	38,000
Annual IC Time Burden (Hours)	12,667	12,667
Annual IC Cost Burden (Dollars)	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.