Information Collection

Written Notice Of Beneficiary Rights

IC 213471 under ICR 201608-2900-010 · OMB 2900-0828.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
VA_Written Noticemof Beneficiary Rights and Referral Request WRITTEN NOTICE OF BENEFICIARY RIGHTS	Form and Instruction
VA_Written Noticemof Beneficiary Rights and Referral Req AP05 Beneficiary Notice_VA_6.23.16.docx	Form and Instruction

IC Title:

WRITTEN NOTICE OF BENEFICIARY RIGHTS

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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				No		Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 190,700

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	190,700	190,700
Annual IC Time Burden (Hours)	64	64
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.

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