REQUEST FOR HEALTH BENEFITS UNDER THE PROGRAM FOR THE HANDICAPPED/BASIC PROGRAM

ICR 198904-0704-021

OMB: 0704-0099

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0704-0099 198904-0704-021
Historical Active 198904-0704-014
DOD/DODDEP
REQUEST FOR HEALTH BENEFITS UNDER THE PROGRAM FOR THE HANDICAPPED/BASIC PROGRAM
No material or nonsubstantive change to a currently approved collection   No
Emergency 04/11/1989
Approved with change 04/11/1989
Retrieve Notice of Action (NOA) 04/11/1989
  Inventory as of this Action Requested Previously Approved
09/30/1989 09/30/1989 09/30/1989
10,000 0 10,000
5,000 0 5,000
0 0 0

THE REQUEST FOR HEALTH BENEFITS UNDER THE PROGRAM FOR THE HANDICAPPED AND BASIS PROGRAM IS AN OFFICIAL APPLICATION FOR CHAMPUS BENEFITS. IT IS USED TO ENSURE THAT CAMPUS BENEFITS ARE BEING PROVIDED ONLY TO THOSE PERSON ENTITLED TO CHAMPUS. THE FORM REQUESTS PERTINENT SPONSOR/BENEFICIARY INFORMATION NECESSARY FOR ISSUING AUTHORIZATION FOR PAYMENT.

None
None


No

1
IC Title Form No. Form Name
REQUEST FOR HEALTH BENEFITS UNDER THE PROGRAM FOR THE HANDICAPPED/BASIC PROGRAM CHAMPUS 190, 190A

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 10,000 10,000 0 0 0 0
Annual Time Burden (Hours) 5,000 5,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
04/11/1989


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