Submitting Payment Information

TSA Claims Application

Documents and Forms

Document Name Document Type
0-0-1 Approval.rtf Other-Letter
0-0-2 Settlement.rtf Other-Letter
0-0-9 Reeval- Settlement.rtf Other-Letter
0-0-10 Reeval -Settlement 50%.rtf Other-Letter
TSA-Form600_FINALv240603 (1_PRAstmt).docx Other-PRA Stmt Mockup
600 Authorization for Disclosure of Protected Health Informa TSA-Form600_FINALv240603 (1).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Submitting Payment Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Letter			0-0-1 Approval.rtf	Yes	Yes	Fillable Printable
Other-Letter			0-0-2 Settlement.rtf	Yes	Yes	Fillable Printable
Other-Letter			0-0-9 Reeval- Settlement.rtf	Yes	Yes	Fillable Printable
Other-Letter			0-0-10 Reeval -Settlement 50%.rtf	Yes	Yes	Fillable Printable
Form and Instruction	600	Authorization for Disclosure of Protected Health Information Pursuant to HIPAA	TSA-Form600_FINALv240603 (1).pdf	Yes	Yes	Fillable Fileable
Other-PRA Stmt Mockup			TSA-Form600_FINALv240603 (1_PRAstmt).docx	Yes	Yes	Fillable Fileable

Line of Business: Homeland Security

Subfunction: Border and Transportation Security

Privacy Act System of Records
Title: DHS/TSA 013 DHS Claims Records	FR Citation: 73 FR 63987

Number of Respondents: 900	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	900	-350	1,250
Annual IC Time Burden (Hours)	150	-58	208
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.