Information Collection

Application And Claim For Sickness Insurance Benefits

IC 176978 under ICR 198408-3220-005 · OMB 3220-0039.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0039 can be found here:

Documents and Forms

Document Name Document Type

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Information Collection (IC) Details

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IC Title:	APPLICATION AND CLAIM FOR SICKNESS INSURANCE BENEFITS	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:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	SI-2	No	No
Form	SI-3	No	No
Form	ID-11A	No	No
Form	SI-1A/B	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 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	575,000	36,072	-109,072	648,000
Annual IC Time Burden (Hours)	24,233	1,433	-4,333	27,133
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

Title	Document	Date Uploaded

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