Information Collection

Installment Agreement On Beneficiary Refund Of Overpayment -- Hcfa-pub. 13-3, Section 3711.9 And Hcfa-pub. 14-3, Section 7120.9 -- "medicare"

IC 113125 under ICR 199208-0938-003 · OMB 0938-0211.

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Information Collection (IC) Details

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IC Title:	INSTALLMENT AGREEMENT ON BENEFICIARY REFUND OF OVERPAYMENT -- HCFA-PUB. 13-3, SECTION 3711.9 AND HCFA-PUB. 14-3, SECTION 7120.9 -- "MEDICARE"	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-9005				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,990	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,990	3,990
Annual IC Time Burden (Hours)	638	638
Annual IC Cost Burden (Dollars)	0	0

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