Information Collection

Additional Information to Be Shared with the Initial Payment or Notice of Denial of Payment

IC 254938 under ICR 202606-1210-003 · OMB 1210-0169.

Documents and Forms

Document Name Document Type
CMS-10780 - Standard Notice and Consent.pdf Other-Document Removed

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Additional Information to Be Shared with the Initial Payment or Notice of Denial of Payment	Agency IC Tracking Number:

Is this a Common Form? Yes		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 29 CFR 2590

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Document Removed			CMS-10780 - Standard Notice and Consent.pdf		No		Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

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

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 95 %

	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	0	0	0	0	0	0
Annual IC Time Burden (Hours)	0	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	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.

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