SF 3881 ACH Vendor/Miscellaneous Payment Enrollment Form

World Trade Center Health Program Enrollment & Appeals - Pentagon & Shanksville, PA Responders

Documents and Forms

Document Name Document Type
Form SF 3881 SF 3881 ACH Vendor/Miscellaneous Payment Enrollment Form Form
SF 3881 ACH Form Appendix D ACH Vendor_Miscellaneous Payment Enrollment Form SF 3881.pdf Form

Information Collection (IC) Details

IC Title:	SF 3881 ACH Vendor/Miscellaneous Payment Enrollment Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	SF 3881	ACH Form	Appendix D ACH Vendor_Miscellaneous Payment Enrollment Form SF 3881.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Occupational Health epidemiological Studies and EEOICPA Program Records and WTC Probram Records	FR Citation: 78 FR 31212

Number of Respondents: 5	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	5	5
Annual IC Time Burden (Hours)	1	1
Annual IC Cost Burden (Dollars)	0	0

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.