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Third Party Liability Information Statement 42 CFR 433.136-.139
Third Party Liability Information Statement 42 CFR 433.136-.139
OMB: 0960-0323
IC ID: 43701
OMB.report
SSA
OMB 0960-0323
ICR 200606-0960-004
IC 43701
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0323 can be found here:
2021-09-10 - Revision of a currently approved collection
2018-06-25 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Third Party Liability Information Statement 42 CFR 433.136-.139
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.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
SSA-8019-U2
Yes
Yes
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
73,540
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
90 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
73,540
0
0
-21,460
0
95,000
Annual IC Time Burden (Hours)
6,128
0
0
-1,789
0
7,917
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.