Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
a) State Notification of Receipt of Authorization (Electronic Process) Modified 97330 1622 0 Other-Internet Screens
b) State Submission of Copy of Authorization (Manual Process) Unchanged 68405 3420 0
c) State Notification to SSA of Amount of Reimbursement Unchanged 101352 13514 0
d) State Request for Determination--Dispute Resolution Unchanged 2 1 0
e) Paper Form SSA-L8125-F6 Modified 1524 762 0 Form and Instruction SSA-L8125-F6 Supplemental Security Income Notice of Interim Assistance Reimbursement
Other-Internet screens (revised)
f) State Notification to SSA of Deceased Claimant Unchanged 40 10 0
g) Review/Signing Agreements Unchanged 38 456 0
h) Maintenance of Authorization Forms Unchanged 165735 8287 0
i) Maintenance of Accounting Forms and Notices Unchanged 101352 5068 0
j) Written Notice from State to Recipient Regarding Amount of Payment Unchanged 101352 11824 0
k) Retrieve and Consolidate Authorization and Accounting Forms Unchanged 12 36 0
l) Participate in Periodic Review Unchanged 12 192 0
m) Correct Administrative and Accounting Discrepancies Unchanged 6 24 0
Total burden requested under this ICR: 637160 45216 0  
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