Document Name Document Type
Compensation Attachment 1.docx Instruction
Compensation Attachment 1 for Reps.docx Instruction
Compensation Attachment 1 for Estate.docx Instruction
1.2 Unreimbursed Medical Expenses Certification (Attach 2) Unreimbursed Medical Expenses Certification (Attach 2).docx Form
1.3 Lost Employment Income Certification (Attach 3).docx Lost Employment Income Certification (Attach 3).docx Form
3.2 Certification of Status for Death Benefit - Alternative Certification of Status for Death Benefit - Alternative Calculation (Attachment 2).docx Form
3.3 Lost Employment Income Certification - Estate (attatchme Lost Employment Income Certification - Estate (attatchment 3).docx Form
3.4 Unreimbursed Medical Expenses Certification - Estate (At Unreimbursed Medical Expenses Certification - Estate (Attachment 4).docx Form
4.1 Certification of Status for Death Benefit - Standard Cal Certification of Status for Death Benefit - Standard Calculation (Attachment 1).docx Form
4.2 Death Benefit Certification of Relationship (Survivor At Death Benefit Certification of Relationship (Survivor Attach 2).docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Benefits Package and Supporting Documentation	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Compensation Attachment 1.docx	Yes	No	Paper Only
Form	1.2	Unreimbursed Medical Expenses Certification (Attach 2)	Unreimbursed Medical Expenses Certification (Attach 2).docx	Yes	No	Paper Only
Form	1.3	Lost Employment Income Certification (Attach 3).docx	Lost Employment Income Certification (Attach 3).docx	Yes	No	Paper Only
Instruction			Compensation Attachment 1 for Reps.docx	Yes	No	Paper Only
Instruction			Compensation Attachment 1 for Estate.docx	Yes	No	Paper Only
Form	3.2	Certification of Status for Death Benefit - Alternative Calculation (Attachment 2)	Certification of Status for Death Benefit - Alternative Calculation (Attachment 2).docx	Yes	No	Paper Only
Form	3.3	Lost Employment Income Certification - Estate (attatchment 3)	Lost Employment Income Certification - Estate (attatchment 3).docx	Yes	No	Paper Only
Form	3.4	Unreimbursed Medical Expenses Certification - Estate (Attachment 4)	Unreimbursed Medical Expenses Certification - Estate (Attachment 4).docx	Yes	No	Paper Only
Form	4.1	Certification of Status for Death Benefit - Standard Calculation (Attachment 1)	Certification of Status for Death Benefit - Standard Calculation (Attachment 1).docx	Yes	No	Paper Only
Form	4.2	Death Benefit Certification of Relationship (Survivor Attach 2).docx	Death Benefit Certification of Relationship (Survivor Attach 2).docx	Yes	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	0	0

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.

Benefits Package and Supporting Documentation