PHYSICIAN'S STATEMENT REGARDING PATIENT'S CAPABILITY TO MANAGE PAYMENTS

ICR 198002-3220-002

OMB: 3220-0103

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
3220-0103 198002-3220-002
Historical Active 197908-3220-010
RRB
PHYSICIAN'S STATEMENT REGARDING PATIENT'S CAPABILITY TO MANAGE PAYMENTS
Revision of a currently approved collection   No
Regular
Approved without change 03/19/1980
Retrieve Notice of Action (NOA) 02/19/1980
  Inventory as of this Action Requested Previously Approved
02/28/1981 02/28/1981 03/31/1980
5,000 0 3,000
417 0 500
0 0 0

THE RETIREMENT ACT PROVIDES FOR PAYMENT OF BENEFITS DUE AN INCOMPETENT ANNUITANT TO A REPRESENTATIVE PAYEE APPOINTED TO RECEIVE PAYMENTS IN THE ANNUITANT'S BEHALF. THE STATEMENT WILL OBTAIN INFORMATION ABOUT THE ANNUITANT'S IMPAIRMENT AND INABILITY TO MANAGE FUNDS. THE INFORMATION WILL BE USED FOR DETERMINING IF A REPRESENTATIVE PAYEE SHOULD BE APPOINTED.

None
None


No

1
IC Title Form No. Form Name
PHYSICIAN'S STATEMENT REGARDING PATIENT'S CAPABILITY TO MANAGE PAYMENTS G-478

  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 5,000 3,000 0 0 2,000 0
Annual Time Burden (Hours) 417 500 0 0 -83 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.
02/19/1980


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