Third Party Liability Information Statement

⚠️ Notice: This information collection may be referencing outdated material.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
MSSICS Screens for Third Party Liability Inputs - 010912.doc Other-MSSIC 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-MSSIC Screens			MSSICS Screens for Third Party Liability Inputs - 010912.doc		Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 66,904	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	66,904	4,699	62,205
Annual IC Time Burden (Hours)	5,575	391	5,184
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.