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Federal forms, ICRs, and supporting documents

Information Collection

Third Party Liability Information Statement - Paper SSA-8019

IC 189371 under ICR 202104-0960-012 · OMB 0960-0323.

Documents and Forms
Document Name
Document Type
Form
Form
Other-Revised PA and PRA Statements
Other-Revised PA and PRA Statements
Form
Form
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Third Party Liability Information Statement - Paper SSA-8019
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 433.136-139

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form SSA-8019 Third Party Liability Information Statement SSA-8019 - (revised).pdf No   Printable Only
Other-Revised PA and PRA Statements Revised PA & PRA Statements.pdf No   Printable Only

Income Security General Retirement and Disability

 

200 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 200 0 0 0 0 200
Annual IC Time Burden (Hours) 20 0 0 3 0 17
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
SSA-8019 - Current SSA-8019 - Current.pdf 09/03/2021
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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