Information Collection

Written Notice Of Beneficiary Rights

IC 213471 under ICR 201410-2900-007 · OMB 2900-0828.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0828 can be found here:

Documents and Forms

Document Name Document Type
WRITTEN NOTICE OF BENEFICIARY RIGHTS Form and Instruction
Written Notice of Beneficiary Righst and Refferal Reques Written Notice of Beneficiary Rights and Referral Request 12-29-14(edite (FINAL 1.9.15).doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	WRITTEN NOTICE OF BENEFICIARY RIGHTS	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 and Instruction	N/A	Written Notice of Beneficiary Righst and Refferal Request	Written Notice of Beneficiary Rights and Referral Request 12-29-14(edite (FINAL 1.9.15).doc		No		Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	58	58
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.