Information Collection

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

IC 13834 under ICR 200707-1215-004 · OMB 1215-0151.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CA-1032 Request for Information on Earnings, Dual Benefits, Dependents and Third Part Settlements	Form
CA-1032 Request for Information on Earnings, Dual Benefits, Depe CA-1032.rtf	Form

IC Title:

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 10.528

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CA-1032	Request for Information on Earnings, Dual Benefits, Dependents and Third Party Settlement	CA-1032.rtf		No		Paper Only

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records

Title: DOL/GOVT-1

FR Citation: 58 FR 49556

Number of Respondents: 50,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	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)	22,000	2,000	20,000

Documents for IC

table that charts IC Documents
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.