Information Collection

Written Notice Of Beneficiary Rights

IC 213471 under ICR 201608-2900-010 · OMB 2900-0828.

Documents and Forms

Document Name Document Type
WRITTEN NOTICE OF BENEFICIARY RIGHTS Form and Instruction
VA_Written Noticemof Beneficiary Rights and Referral Req AP05 Beneficiary Notice_VA_6.23.16.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	WRITTEN NOTICE OF BENEFICIARY RIGHTS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	N/A	VA_Written Noticemof Beneficiary Rights and Referral Request	AP05 Beneficiary Notice_VA_6.23.16.docx		No		Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 190,700	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	190,700	190,700
Annual IC Time Burden (Hours)	64	64
Annual IC Cost Burden (Dollars)	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.