Information Collection

Claimant's Statement When Request for Hearing is Filed and the Issue is Disability

IC 9212 under ICR 200102-0960-004 · OMB 0960-0316.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

Claimant's Statement When Request for Hearing is Filed and the Issue is Disability

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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HA-4486				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 442,720

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	442,720	4,276	438,444
Annual IC Time Burden (Hours)	110,680	1,069	109,611
Annual IC Cost Burden (Dollars)	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.