Information Collection

Third Party Liability Information Statement

IC 189371 under ICR 201802-0960-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form SSA-8019-U2 Third Party Liability Information Statement Form
Privacy Act Statement (revised).doc Other-Privacy Act Statement (revised
SSA-8019-U2 Third Party Liability Information Statement SSA-8019 (revised).pdf Form
SSA-8019-current.pdf SSA-8019 Current Version IC Document

Information Collection (IC) Details

View Information Collection (IC)

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:

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
Other-Privacy Act Statement (revised) 0323			Privacy Act Statement (revised).doc		Yes	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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	17	17
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-8019 Current Version	SSA-8019-current.pdf	04/10/2018

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