MEDICARE PART B CERTIFICATION

ICR 198911-3206-003

OMB: 3206-0017

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
156655 Migrated
ICR Details
3206-0017 198911-3206-003
Historical Active 198610-3206-002
OPM
MEDICARE PART B CERTIFICATION
Extension without change of a currently approved collection   No
Regular
Approved without change 01/05/1990
Retrieve Notice of Action (NOA) 11/01/1989
  Inventory as of this Action Requested Previously Approved
11/30/1992 11/30/1992 11/30/1989
300 0 300
50 0 50
0 0 0

RETIREMENT BENEFITS, HEALTH INSURANCE, EMPLOYEE BENEFITS' THIS FORM IS USED TO DETERMINE ELIGIBILITY FOR A GOVERNMENT CONTRIBUTION TOWARDS PART B OF MEDICARE FOR ANNUITANTS AND SURVIVOR ANNUITANTS UNDER THE RETIRED FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM.

None
None


No

1
IC Title Form No. Form Name
MEDICARE PART B CERTIFICATION RI 78-11

  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 300 300 0 0 0 0
Annual Time Burden (Hours) 50 50 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.
11/01/1989


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