OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Claimant's Medications - ERE Internet Version

IC 189495 under ICR 202407-0960-005 · OMB 0960-0289.

Documents and Forms
Document Name
Document Type
Other-Internet Screens
Other-Revised Privacy Act Statement
Form
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Claimant's Medications - ERE Internet Version
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 406.912 20 CFR 404.1512

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Internet Screens Electronic Record Express - Representative Upload Files Instructions (Internet Screens).pdf Yes Yes Fillable Fileable Signable
Form HA-4632 Claimant's Medications HA-4632 - Revised Version.pdf www.ssa.gov Yes Yes Fillable Fileable Signable
Other-Revised Privacy Act Statement Revised PA Statement - HA-4632.pdf Yes No Printable Only

Income Security Survivor Compensation

 

249,000 0
   
Individuals or Households
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 249,000 0 0 112,200 0 136,800
Annual IC Time Burden (Hours) 83,000 0 0 48,800 0 34,200
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Current HA-4632 HA-4632 - Current Version.pdf 12/13/2024
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.