Information Collection

Third Party Liability Information Statement - Paper SSA-8019

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-8019 Third Party Liability Information Statement	Form
Form SSA-8019 Third Party Liability Information Statement Third Party Liability Information Statement - Paper SSA-8019	Form
Revised PA & PRA Statements.pdf	Other-Revised PA and PRA Statements
Revised PA & PRA Statements.pdf	Other-Revised PA and PRA Statements
SSA-8019 Third Party Liability Information Statement SSA-8019 - Revised.pdf	Form
SSA-8019 Third Party Liability Information Statement SSA-8019 - (revised).pdf	Form
SSA-8019 - Current.pdf SSA-8019 - Current	IC Document
SSA-8019 - Current.pdf SSA-8019 - Current	IC Document

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-8019				No		Printable Only
Other-Revised PA and PRA Statements					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 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	200	0	200
Annual IC Time Burden (Hours)	20	3	17
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-8019 - Current		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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