Information Collection

Third Party Liability Information Statement

IC 43701 under ICR 201802-0960-003 · OMB 0960-0323.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0323 can be found here:

Documents and Forms

Document Name Document Type
SSI Claims System screens.doc Other-Internal Screens

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Third Party Liability Information Statement	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 433.136-139

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Internal Screens			SSI Claims System screens.doc		Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 49,621	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 99 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	49,621	-1,760	51,381
Annual IC Time Burden (Hours)	4,135	-147	4,282
Annual IC Cost Burden (Dollars)	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.