Information Collection

Third Party Liability Information Statement

IC 189371 under ICR 201504-0960-001 · OMB 0960-0323.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0323 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-8019-U2 Third Party Liability Information Statement	Form
SSA-8019-U2 Third Party Liability Information Statement SSA-8019 (revised).pdf	Form
ssa8019(current).pdf SSA-8019 Current Version	IC Document

IC Title:

Third Party Liability Information Statement

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 433.136-139

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	SSA-8019-U2	Third Party Liability Information Statement	SSA-8019 (revised).pdf		No		Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	200	70	130
Annual IC Time Burden (Hours)	17	6	11
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-8019 Current Version	ssa8019(current).pdf	05/05/2015

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.