Information Collection

Application and Claim for Sickness Insurance Benefits

IC 157400 under ICR 199501-3220-001 · OMB 3220-0039.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0039 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

No indexed documents/forms are available for this IC yet. A refresh has been queued.

IC Title:

Application and Claim for Sickness Insurance Benefits

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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	SI-1A	No	No
Form	SI-1B	No	No
Form	SI-3	No	No
Form	SI-7	No	No
Form	SI-8	No	No
Form	ID-7H	No	No
Form	ID-11A	No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 93,400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	333,600	-279,053	612,653	0
Annual IC Time Burden (Hours)	33,591	2,650	-5,818	36,759
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

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