Information Collection

Third Party Liability Information Statement 42 CFR 433.136-.139

IC 43701 under ICR 200606-0960-004 · OMB 0960-0323.

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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: Voluntary

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: 73,540	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	73,540	-21,460	95,000
Annual IC Time Burden (Hours)	6,128	-1,789	7,917
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.