Information Collection

Third Party Liability Information Statement - SSI Claims System

IC 43701 under ICR 202104-0960-012 · OMB 0960-0323.

Documents and Forms

Document Name Document Type
SSI Claims System Screens.docx Other-Internal Screens
SSI Claims System Screens.docx Other-Internal Screens

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Third Party Liability Information Statement - SSI Claims System	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
Other-Internal Screens			SSI Claims System Screens.docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 35,257	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 99 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	35,257	-14,364	49,621
Annual IC Time Burden (Hours)	15,866	11,731	4,135
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].