Medicare Part B Certification

ICR 200507-3206-002

OMB: 3206-0017

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
33541 Migrated
ICR Details
3206-0017 200507-3206-002
Historical Active 200206-3206-003
OPM
Medicare Part B Certification
Revision of a currently approved collection   No
Regular
Approved without change 10/07/2005
Retrieve Notice of Action (NOA) 07/29/2005
  Inventory as of this Action Requested Previously Approved
10/31/2008 10/31/2008 10/31/2005
100 0 100
17 0 17
0 0 0

RI-78-11 collects information from annuitants, their spouses, and survivor annuitants to determine their eligibility under the Retired Employees Health Benefits Program for a Government contribution toward the cost of Part B of Medicare.

None
None


No

1
IC Title Form No. Form Name
Medicare Part B Certification RI-78-11

  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 100 100 0 0 0 0
Annual Time Burden (Hours) 17 17 0 0 0 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.
07/29/2005


© 2024 OMB.report | Privacy Policy