Information Collection Request
Third Party Collection Program (Insurance Information)
ICR 202210-0720-001 · OMB 0720-0055 · Active
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0720-0055 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form DD Form 2569 Third Party Collection Program (Insurance Information) |
Form | Modified | Available |
 0720-0055_SSA_9.8.22.docx |
Supporting Statement A | Uploaded 2022-10-21 | Available |
 DD 2569 SSN Justification Memo.pdf |
Supplementary Document | Uploaded 2022-10-21 | Available |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 5378 |  Third Party Collection Program (Insurance Information) |
Form | Modified | |
| 256564 | e2569 Module |
Other-Screenshots | New |
ICR Details
| Status | Active |
|---|---|
| Agency/Subagency | DOD/DODOASHA |
| OMB Control No | 0720-0055 |
| Type of Information Collection | Revision of a currently approved collection |
| Previous ICR Reference No | 201908-0720-002 |
| Date Submitted to OIRA | 2022-10-24 |
| Requested Expiration Date | 1969-12-31 |