Information Collection

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

IC 13834 under ICR 202003-1240-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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 and Instruction
CA-1032 Request for Information on Earnings, Dual Benefits, Depe Request for Information on Earnings, Dual Benefits, Dependents and Third Party Settlements (CA-16).docx	Form and Instruction

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 and Instruction	CA-1032	Request for Information on Earnings, Dual Benefits, Dependents, and Third Party Settlement	Request for Information on Earnings, Dual Benefits, Dependents and Third Party Settlements (CA-16).docx		No		Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: DOL/GOVT-1

FR Citation: 81 FR 47418

Number of Respondents: 37,056

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 26 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	37,056	-8,105	45,161
Annual IC Time Burden (Hours)	12,352	-2,702	15,054
Annual IC Cost Burden (Dollars)	15,030	9,864	5,166

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.