OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

APPLICATION FOR CONTRIBUTION TOWARD THE COST OF PART B (MEDI CAL INSURANCE OF MEDICARE

ICR 197602-3206-003 · OMB 3206-0017 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
176559 APPLICATION FOR CONTRIBUTION TOWARD THE COST OF PART B (MEDI CAL INSURANCE OF MEDICARE Form Migrated
ICR Details
3206-0017 197602-3206-003
Historical Active
OPM
APPLICATION FOR CONTRIBUTION TOWARD THE COST OF PART B (MEDI CAL INSURANCE OF MEDICARE
No material or nonsubstantive change to a currently approved collection   No
Emergency 02/11/1976
Approved with change 02/11/1976
Retrieve Notice of Action (NOA) 02/11/1976
  Inventory as of this Action Requested Previously Approved
06/30/1978 06/30/1978
151,500 0 0
7,750 0 0
0 0 0

None
None
No
1
IC Title Form No. Form Name
APPLICATION FOR CONTRIBUTION TOWARD THE COST OF PART B (MEDI CAL INSURANCE OF MEDICARE SF2814-A
  Total Approved 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 151,500 0 0 0 151,500 0
Annual Time Burden (Hours) 7,750 0 0 0 7,750 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
  No
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
02/11/1976