View Information Collection (IC)

View Information Collection (IC)

IC Title:	Request for Information on Earnings, Dual Benefits, Dependents, and Third Part Settlements	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 10.528

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CA-1032	Request for Information on Earnings, Dual Benefits, Dependents, and Third Party Settlement	CA-1032 Revised january 2017 cpc suggest jv (2) mjs 2-21-2017ad final 2-22-2017.doc		No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title: DOL/GOVT-1	FR Citation: 67 FR 16826

Number of Respondents: 45,161	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 25 %

	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	45,161	0	0	361	0	44,800
Annual IC Time Burden (Hours)	15,054	0	0	121	0	14,933
Annual IC Cost Burden (Dollars)	5,166	0	0	-18,130	0	23,296

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.