Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form HA-85 20 CFR 404.971 and 416.1471 (HA-85, Request to Withdraw a Hearing Request; HA-86, Request to Withdraw an Appeals Council Request for Review)	Form	Modified	Missing upstream
Addendum - 0710 (Final).docx	Supplementary Document	Uploaded 2022-10-17	Missing upstream
Supporting Statement - 0710 (Final).docx	Supporting Statement A	Uploaded 2022-10-17	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9767	20 CFR 404.961, 416.1461, 405.330, 405.366		Modified
237195	20 CFR 404.1512, 404.1740(c)(4), 416.912, and 416.1540(c)(4)		Modified
237194	20 CFR 1540(b)(1)		Modified
237193	20 CFR 404.1740(b)(1)		Modified
206582	20 CFR 404.971 and 416.1471 (HA-85, Request to Withdraw a Hearing Request; HA-86, Request to Withdraw an Appeals Council Request for Review)	Form	Modified
197304	20 CFR 405.20		Modified
197303	20 CFR 405.1(c)(2)		Modified
197302	20 CFR 405.505		Modified
197301	20 CFR 405.1(b)(5) and 405.372(b)		Modified
197300	20 CFR 405.372(c)		Modified
197299	20 CFR 405.401		Modified
187625	20 CFR 404.987 & 404.988, 416.1487 & 4161488, and 405.601		Modified
187624	20 CFR 404.982 & 416.1482		Modified
187622	20 CFR 405.381		Modified
187620	20 CFR 404.957, 416.1457, 405.380		Modified
187619	20 CFR 405.334		Modified
187618	20 CFR 404.949 and 416.1449		Modified
187617	20 CFR 404.950, 416.1450, 405.332		Modified

ICR Details

OMB Control No:	ICR Reference No:
Status:	Previous ICR Reference No:
Agency/Subagency:	Agency Tracking No:
Title:
Type of Information Collection:	Common Form ICR:
Type of Review Request:	Date Received in OIRA:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract:

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR?

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Number of Information Collection (IC) in this ICR: 0

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ICR Summary of Burden

table that charts list of burden

	Total	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	0	0	0	0	0	0
Annual Time Burden (Hours)	0	0	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion:

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion:

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government:

Does this IC contain surveys, censuses, or employ statistical methods?

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.    

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.    

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?

Is this ICR related to the Pandemic Response?

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Common Form ICR: 

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date:

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