Information Collection

Third Party Liability Information Statement - 42 CFR 433.136-.139

IC 9215 under ICR 200306-0960-003 · OMB 0960-0323.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0323 can be found here:

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Information Collection (IC) Details

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IC Title:	Third Party Liability Information Statement - 42 CFR 433.136-.139	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	SSA-8019-U2				Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 95,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 83 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	95,000	4,500	90,500
Annual IC Time Burden (Hours)	7,917	375	7,542
Annual IC Cost Burden (Dollars)	0	0	0

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