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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.