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Information Collection

Request For Termination Of Supplementary Medical Insurance

IC 177119 under ICR 198804-3220-005 · OMB 3220-0098.

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Information Collection (IC) Details

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REQUEST FOR TERMINATION OF SUPPLEMENTARY MEDICAL INSURANCE
 
No Migrated
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability


    

150 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 150 0 0 0 0 150
Annual IC Time Burden (Hours) 13 0 0 0 0 13
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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