Approved for use
through 12/91 under the condition that the next HCFA-379 submitted
for OMB approval incorporates the burden disclosure statement
pursuant to 5 CFR 1320.
Inventory as of this Action
Requested
Previously Approved
12/31/1991
12/31/1991
500
0
0
1,000
0
0
0
0
0
THIS FORM IS USED TO OBTAIN FINANCIAL
INFORMATION NEEDED TO EVALUATE REQUESTS FROM PHYSICIANS OR
SUPPLIERS TO PAY AN INDEBTEDNE UNDER AN EXTENDED REPAYMENT
SCHEDULE, OR TO COMPROMISE A DEBT FOR LESS THAN THE FULL
AMOUNT.
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.