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 76703 1278 0 Other-Internet Screens
b) State Submission of Copy of Authorization (Manual Process) Modified 51138 2557 0 Other-Sample MOU
Other-Sample Signed Agreement
Other-Sample Signed Agreement Appendecies
c) State Notification to SSA of Amount of Reimbursement Modified 51148 6820 0 Other-Internet Screens
d) State Request for Determination--Dispute Resolution Modified 2 1 0
e) State Computation of Reimbursement Due from SSA Using Paper Form SSA-L8125 or eIAR Modified 38 19 0 Form and Instruction SSA-L8125-F6 Supplemental Security Income Notice of Interim Assistance Reimbursement
Other-Revised Privacy Act Statement
Other-Internet Screens
f) State Notification to SSA of Deceased Claimant Modified 40 10 0 Other-Internet Screens
g) Review/Signing Agreements Modified 38 456 0 Other-MOU
Other-Sample Signed Agreement
Other-Sample Signed Agreement Appendecies
h) Maintenance of Authorization Forms Modified 127832 6392 0
i) Maintenance of Accounting Forms and Notices Modified 51148 2557 0
j) Written Notice from State to Recipient Regarding Amount of Payment Modified 101384 11828 0
k) Retrieve and Consolidate Authorization and Accounting Forms Modified 12 36 0
l) Participate in Periodic Review Modified 12 192 0
m) Correct Administrative and Accounting Discrepancies Modified 6 24 0
Total burden requested under this ICR: 459501 32170 0  
To view an IC, click on IC Title