Information Collection

Components of an Insurance Match Agreement

IC 183594 under ICR 201710-0970-004 · OMB 0970-0342.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0342 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Components of an Insurance Match Agreement	Form and Instruction
1 File input 01 Standard Input File.doc	Form and Instruction

IC Title:

Components of an Insurance Match Agreement

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Voluntary

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	1	File input	01 Standard Input File.doc		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 28

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-336	336
Annual IC Time Burden (Hours)	-168	168
Annual IC Cost Burden (Dollars)	-1,680	1,680

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.