Information Collection

Request for Information on Earnings, Dual Benefits, Dependents, and Third Part Settlements

IC 13834 under ICR 201701-1240-003 · OMB 1240-0016.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0016 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CA-1032 Request for Information on Earnings, Dual Benefits, Dependents, and Third Part Settlements	Form
CA-1032 Request for Information on Earnings, Dual Benefits, Depe CA-1032 Revised january 2017 cpc suggest jv (2) mjs 2-21-2017ad final 2-22-2017.doc	Form

IC Title:

Request for Information on Earnings, Dual Benefits, Dependents, and Third Part Settlements

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 10.528

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	CA-1032	Request for Information on Earnings, Dual Benefits, Dependents, and Third Party Settlement	CA-1032 Revised january 2017 cpc suggest jv (2) mjs 2-21-2017ad final 2-22-2017.doc		No		Paper Only

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records

Title: DOL/GOVT-1

FR Citation: 67 FR 16826

Number of Respondents: 45,161

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 25 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	45,161	361	44,800
Annual IC Time Burden (Hours)	15,054	121	14,933
Annual IC Cost Burden (Dollars)	5,166	-18,130	23,296

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.