THIRD PARTY LIABILITY INFORMATION STATEMENT

ICR 199012-0960-005

OMB: 0960-0323

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
115312 Migrated
ICR Details
0960-0323 199012-0960-005
Historical Active 198712-0960-002
SSA
THIRD PARTY LIABILITY INFORMATION STATEMENT
Extension without change of a currently approved collection   No
Regular
Approved without change 02/19/1991
Retrieve Notice of Action (NOA) 12/19/1990
  Inventory as of this Action Requested Previously Approved
02/28/1994 02/28/1994 02/28/1991
65,400 0 65,400
5,450 0 5,450
0 0 0

THE INFORMATION COLLECTED BY THIS FORM IS USED BY THE SOCIAL SECURITY ADMINISTRATION TO RECORD COMMERCIAL HEALTH INSURANCE INFORMATION FROM APPLICANTS AND RECIPIENTS OF SUPPLEMENTAL SECURITY INCOME (SSI) AND MEDICAID BENEFITS FOR THE PURPOSE OF ESTABLISHING HIS/HER CONTINUING ENTITLEMENT TO MEDICAID BENEFITS. THE AFFECTED PUBLIC IS COMPRISED OF

None
None


No

1
IC Title Form No. Form Name
THIRD PARTY LIABILITY INFORMATION STATEMENT SSA-8019-U2

  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 65,400 65,400 0 0 0 0
Annual Time Burden (Hours) 5,450 5,450 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.
12/19/1990


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