Information Collection

Installment Agreement On Beneficiary Refund Of Overpayment, Hcfa-pub.13-3, Section 3711.9, & Hcfa-pub.14.3, Section 7120.0, Hcfa-r-9005

IC 113123 under ICR 198502-0938-006 · OMB 0938-0211.

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Information Collection (IC) Details

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IC Title:	INSTALLMENT AGREEMENT ON BENEFICIARY REFUND OF OVERPAYMENT, HCFA-PUB.13-3, SECTION 3711.9, & HCFA-PUB.14.3, SECTION 7120.0, HCFA-R-9005	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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-9005				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12,400	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	12,400	-468,600	481,000
Annual IC Time Burden (Hours)	1,985	-358,765	360,750
Annual IC Cost Burden (Dollars)	0	0	0

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