View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

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 Yes Yes Fillable Fileable
Form Survivor - Form 2 Yes Yes Fillable Fileable
Form Survivor - Attachment 1 Yes Yes Fillable Fileable
Form Survivor - Form 3 Yes Yes Fillable Fileable
Form Survivor - Form 1 Yes Yes Fillable Fileable
Instruction Yes Yes Fillable Fileable
Instruction Yes Yes Fillable Fileable
Instruction Yes Yes Fillable Fileable
Form Estate - 1 Yes Yes Fillable Fileable
Form Estate - 2 Yes Yes Fillable Fileable
Form Recipient - 1 Yes Yes Fillable Fileable
Form Recipient - 2 Yes Yes Fillable Fileable

Health Consumer Health and Safety

 

30 0
   
Individuals or Households
 
   80 %

  Requested 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) 300 0 296 0 0 4
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Survivor Package - Certification of Relationship - Redline 03/18/2026
Survivor Package - Compensation Letter - Redline 03/18/2026
Estate Package - Compensation Letter - Redline 03/18/2026
Estate Package - Lost Employment Income (Form) - Redline 03/18/2026
Estate Package - Unreimbursed Medical Expenses (Form) - Redline 03/18/2026
Recipient Package - Compensation Letter - Redline 03/18/2026
Recipient Package - Lost Employment Income - (Form) - Redline 03/18/2026
Recipient Package - Unreimbursed Medical Expenses - (Form) - Redline 03/18/2026
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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