Third Party Collection Program (Insurance Information)

ICR 202210-0720-001

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0720-0055 can be found here:

Forms and Documents

Document Name	Status
Form DD Form 2569 Third Party Collection Program (Insurance Information) Form	Modified
0720-0055_SSA_9.8.22.docx Supporting Statement A	2022-10-21
DD 2569 SSN Justification Memo.pdf Supplementary Document	2022-10-21

IC Document Collections

IC ID	Document Title	Status
5378	Third Party Collection Program (Insurance Information) Form	Modified
256564	e2569 Module Other-Screenshots	New

ICR Details