Information Collection

Request for Information on Earnings, Dual Benefits, Dependents and Third Party Settlements

IC 13833 under ICR 200112-1215-003 · OMB 1215-0151.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1215-0151 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Request for Information on Earnings, Dual Benefits, Dependents and Third Party Settlements	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	CA-1032				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	50,000	0	50,000
Annual IC Time Burden (Hours)	16,667	0	16,667
Annual IC Cost Burden (Dollars)	18,000	1,000	17,000

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.