ACH Vendor/Miscellaneous Payment Enrollment Form

World Trade Center Health Program Enrollment, Appeals & Reimbursement

OMB: 0920-0891

IC ID: 200509

Information Collection (IC) Details

View Information Collection (IC)

ACH Vendor/Miscellaneous Payment Enrollment Form
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 11 ACH Vendor/Miscellaneous Payment Enrollment Form Attachment M SF 3881 ACH Vendor_Misc Payment Enrollment Form.pdf Yes No Paper Only

Health Health Care Services

 

200 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 200 0 0 0 0 200
Annual IC Time Burden (Hours) 50 0 0 0 0 50
Annual IC Cost Burden (Dollars) 0 0 0 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.

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