Representative Fee Request

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1215-0078 can be found here:

Documents and Forms

Document Name Document Type
Form CA-155 Representative Fee Request Form
CA-155 Attorney Fee Letter CA-155 Attorney Fee Letter.rtf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Representative Fee Request	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 702.132 20 CFR 10.700-703

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CA-155	Attorney Fee Letter	CA-155 Attorney Fee Letter.rtf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12,340	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	12,340	-360	12,700
Annual IC Time Burden (Hours)	7,675	-175	7,850
Annual IC Cost Burden (Dollars)	17,401	401	17,000

Documents for IC

Title	Document	Date Uploaded
No associated records found

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