State Death Match - Manual - Non-EDR Records from EDR sites

Statement of Death by Funeral Director and State Death Match

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0142 can be found here:

Documents and Forms

Document Name Document Type
Instructions and File Format for States' Use.docx Other-ile Format for State's Use
Instructions and File Format for States' Use.docx Other-ile Format for State's Use

Information Collection (IC) Details

IC Title:	State Death Match - Manual - Non-EDR Records from EDR sites	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-ile Format for State's Use			Instructions and File Format for States' Use.docx		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 39	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,676,219	2,676,219
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	2,355,073	2,355,073

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.