Information Collection

Application for Medical Benefits, Insurance Information, Financial Analysis Worksheet, and Funeral Arrangements

IC 28248 under ICR 199708-2900-004 · OMB 2900-0091.

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Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

Application for Medical Benefits, Insurance Information, Financial Analysis Worksheet, and Funeral Arrangements

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	L0-10F	No	No
Form	10-10T	No	No
Form	10-10	No	No
Form	L0-10I	No	No
Form	10-2065	No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,336,856

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	7,336,856	-1,813,180	149,186	9,000,850
Annual IC Time Burden (Hours)	2,766,738	-483,333	39,768	3,210,303
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.