Information Collection

Request For Information Concerning Medical, Legal, Or Other Expenses

IC 147375 under ICR 199208-2900-007 · OMB 2900-0161.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0161 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	REQUEST FOR INFORMATION CONCERNING MEDICAL, LEGAL, OR OTHER EXPENSES	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	21-8416				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 96,400	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	Previously Approved
Annual Number of Responses for this IC	96,400	40,000	56,400
Annual IC Time Burden (Hours)	32,133	20,853	11,280
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

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