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Benefits Package and Supporting Documentation
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction Compensation Attachment 1.docx Yes Yes Printable Only
Instruction Compensation Attachment 1 for Reps.docx Yes Yes Printable Only
Instruction Compensation Attachment 1 for Estate.docx Yes Yes Printable Only
Form 4.1 Certification of Status for Death Benefit – Alternate Calculation Certification of Status for Death Benefit - Alternative Calculation.docx Yes Yes Printable Only
Form 4.2 Certification of Status for Death Benefit - Standard Calculation Certification of Status for Death Benefit - Standard Calculation.docx Yes Yes Printable Only
Form 4.3 Certification of Survivor Relationship to Deceased Injured Countermeasure Recipient Death Benefit Certification of Relationship Survivor.docx Yes Yes Printable Only
Form 4.4 Certification of Status for Administrators of the Estate: Lost Employment Income Lost Employment Income Certification - Estate.docx Yes Yes Printable Only
Form 4.5 Certification of Status: Lost Employment Income Lost Employment Income Certification.docx Yes Yes Printable Only
Form 4.6 Certification of Status: Unreimbursed Medical Expenses Unreimbursed Medical Expenses Certification.docx Yes Yes Printable Only
Instruction 10162023 - (08) Recipient Requester Package - Compensation Letter - CLEAN.docx Yes Yes Fillable Fileable
Instruction 10162023 - (09) Recipient Requester Package - Attachment 1 - Documentation Required to Reimburse of Pay for Medical Expenses... - CLEAN.docx Yes Yes Fillable Fileable
Instruction 10162023 - (09) Recipient Requester Package - Attachment 1 - Documentation Required to Reimburse of Pay for Medical Expenses... - REDLINE.docx Yes Yes Fillable Fileable
Form and Instruction Attachment 2 Unreimbursed Medical Expenses Certification A (Clean) 10162023 - (10) Recipient Requester Package - Attachment 2 - Unreimbursed Medical Expenses Certification A - CLEAN.docx Yes Yes Fillable Fileable
Form and Instruction Attachment 2 Unreimbursed Medical Expenses Certification (Redline) 10162023 - (10) Recipient Requester Package - Attachment 2 - Unreimbursed Medical Expenses Certification A - REDLINE.docx Yes Yes Fillable Fileable
Form and Instruction Attachment 3 Lost Employment Income Certification A (Clean) 10162023 - (11) Recipient Requester Package - Attachment 3 - Lost Employment Income Certification A - CLEAN.docx Yes Yes Fillable Fileable
Form and Instruction Attachment 3 Lost Income Certification A (Redline) 10162023 - (11) Recipient Requester Package - Attachment 3 - Lost Employment Income Certification A - REDLINE.docx Yes Yes Fillable Fileable
Instruction 10162023 - (12) Estate Package - Compensation Letter - CLEAN.docx Yes Yes Fillable Fileable
Instruction 10162023 - (12) Estate Package - Compensation Letter - REDLINE.docx Yes Yes Fillable Fileable
Instruction 10162023 - (13) Estate Package - Attachment 1 - Compensation Attachment - CLEAN.docx Yes Yes Fillable Fileable
Instruction 10162023 - (13) Estate Package - Attachment 1 - Compensation Attachment - REDLINE.docx Yes Yes Fillable Fileable
Instruction 10162023 - (14) Survivor Package - Compensation Letter - CLEAN.docx Yes Yes Fillable Fileable
Instruction 10162023 - (14) Survivor Package - Compensation Letter - REDLINE.docx Yes Yes Fillable Fileable
Form and Instruction Attachment 2 - Estate Unreimbrused Medical Expenses Certification (Clean) 10162023 - (15) Estate Package - Attachment 2 - Unreimbursed Medical Expenses Certification - CLEAN.docx Yes Yes Fillable Fileable
Form and Instruction Attachment 2 - Estate Unreimbursed Medical Expenses Certification (redline) 10162023 - (15) Estate Package - Attachment 2 - Unreimbursed Medical Expenses Certification - REDLINE.docx Yes Yes Fillable Fileable
Form and Instruction Attachment 3 - Estate Lost Income Certification 10162023 - (16) Estate Package - Attachment 3 - Lost Employment Income Certification - CLEAN.docx Yes Yes Fillable Fileable
Form and Instruction Attachment 1 - Survivor Certifcation of Status for Death Benefit (clean) 10162023 - (17) Survivor Package - Attachment 1 - Certification of Status for Death Benefit - Standard Calculation - CLEAN.docx Yes Yes Fillable Fileable
Form and Instruction Attachment 1 - Survivor Certification of Status for Death Benefit - Redline 10162023 - (17) Survivor Package - Attachment 1 - Certification of Status for Death Benefit - Standard Calculation - REDLINE.docx Yes Yes Fillable Fileable
Form and Instruction Attachment 2 - Survivor Certification of Status for Death Benefit - Alternative Calculation (Clean) 10162023 - (18) Survivor Package - Attachment 2 - Certification of Status for Death Benefit - Alternative Calculation - CLEAN.docx Yes Yes Fillable Fileable
Form and Instruction Attachment 2 - Survivor Certification of Status for Death Benefit - Alternative Calculation (redline) 10162023 - (18) Survivor Package - Attachment 2 - Certification of Status for Death Benefit - Alternative Calculation - REDLINE.docx Yes Yes Fillable Fileable
Form and Instruction Attachment 3 - Survivor Survivor Attachment 3 - Death Benefit Certification of Relationship Redline 10112023 - (19) Survivor Package - Attachment 3 - Death Benefit Certification of Relationship - REDLINE.docx Yes Yes Fillable Fileable

Health Consumer Health and Safety

 

30 0
   
Individuals or Households
 
   80 %

  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 30 0 0 0 0 30
Annual IC Time Burden (Hours) 4 0 0 0 0 4
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.