Information Collection

Application for Medical Benefits, Insurance Information, Financial Analysis Worksheet, and Funeral Arrangements

IC 28248 under ICR 199708-2900-004 · OMB 2900-0091.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0091 can be found here:

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Information Collection (IC) Details

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IC Title:	Application for Medical Benefits, Insurance Information, Financial Analysis Worksheet, and Funeral Arrangements	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	L0-10F	No	No
Form	10-10T	No	No
Form	10-10	No	No
Form	L0-10I	No	No
Form	10-2065	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,336,856	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	7,336,856	-1,813,180	149,186	9,000,850
Annual IC Time Burden (Hours)	2,766,738	-483,333	39,768	3,210,303
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.