Information Collection

State Death Match - States Expected to Become EDR's within next 3 Years

IC 227858 under ICR 202101-0960-001 · OMB 0960-0700.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Death Screen Images.pdf	Other-Internet Screens for EDR
Death Screen Images.pdf	Other-Internet Screens for EDR
Instructions and File Format for States' Use.docx	Instruction
Instructions and File Format for States' Use.docx	Instruction
DFSTATE Format.docx	Instruction
DFSTATE Format.docx	Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.371 20 CFR 404.316 20 CFR 416.912 20 CFR 404.330-341 20 CFR 404.350-352 20 CFR 404.301 20 CFR 404.310-311

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Internet Screens for EDR	Death Screen Images.pdf	Yes	Yes	Fillable Fileable Signable
Instruction	Instructions and File Format for States' Use.docx	No		Paper Only
Instruction	DFSTATE Format.docx	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	313,000	-125,200	438,200
Annual IC Time Burden (Hours)	0	0	0
Annual IC Cost Burden (Dollars)	992,210	-396,884	1,389,094

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.