Information Collection

Funeral Arrangements Request Form

IC 210686 under ICR 201310-2900-001 · OMB 2900-0080.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0080 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-2065 Funeral Arrangements Request Form	Form
10-2065 FUNERAL ARRANGEMENTS 10-2065_20140313.pdf	Form

IC Title:

Funeral Arrangements Request Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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	10-2065	FUNERAL ARRANGEMENTS	10-2065_20140313.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 22,213

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	22,213	22,213
Annual IC Time Burden (Hours)	3,702	3,702
Annual IC Cost Burden (Dollars)	0	0

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.