Statement Of Personal Injury - Possible Third Party Liability - Champus/champva

STATEMENT OF PERSONAL INJURY - POSSIBLE THIRD PARTY LIABILITY - CHAMPUS/CHAMPVA

OMB: 0704-0090

IC ID: 108638

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STATEMENT OF PERSONAL INJURY - POSSIBLE THIRD PARTY LIABILITY - CHAMPUS/CHAMPVA
 
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
Form DD X379 No No
Form (DRAFT) No No


    

30,000 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 30,000 0 0 30,000 0 0
Annual IC Time Burden (Hours) 17,000 0 0 17,000 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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