Medicaid Use Report -- 20 CFR 216.628

ICR 199912-0960-002

OMB: 0960-0267

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
9168
Migrated
ICR Details
0960-0267 199912-0960-002
Historical Active 199607-0960-006
SSA
Medicaid Use Report -- 20 CFR 216.628
Extension without change of a currently approved collection   No
Regular
Approved without change 01/18/2000
Retrieve Notice of Action (NOA) 12/07/1999
  Inventory as of this Action Requested Previously Approved
02/28/2003 02/28/2003 01/31/2000
60,000 0 25,000
3,000 0 1,250
0 0 0

The information required by this regulation is used by the Social Security Administration to determine if an individual is entitled to special Supplemental Security Income (SSI) payments. The respondents are SSI recipients whose payments were stopped based on earnings.

None
None


No

1
IC Title Form No. Form Name
Medicaid Use Report -- 20 CFR 216.628

  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 60,000 25,000 0 0 35,000 0
Annual Time Burden (Hours) 3,000 1,250 0 0 1,750 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.
12/07/1999


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