69 FR 219 pg. 65662 - Agency Forms Submitted for OMB Review

Type: NOTICEVolume: 69Number: 219Page: 65662
FR document: [FR Doc. 04-25290 Filed 11-12-04; 8:45 am]
Agency: Railroad Retirement Board
Official PDF Version:  PDF Version


Agency Forms Submitted for OMB Review

Summary: In accordance with the Paperwork Reduction Act of 1995 (44 U.S.C. Chapter 35), the Railroad Retirement Board (RRB) has submitted the following proposal(s) for the collection of information to the Office of Management and Budget for review and approval.

Summary of Proposal(s)

(1) Collection title: Report of Medicaid State Office on Beneficiary's Buy-In-Status.

(2) Form(s) submitted: RL-380-F.

(3) OMB Number: 3220-0185.

(4) Expiration date of current OMB clearance: 02/28/2005.

(5) Type of request: Extension of a currently approved collection.

(6) Respondents: State, local or tribal government.

(7) Estimated annual number of respondents: 600.

(8) Total annual responses: 600.

(9) Total annual reporting hours: 100.

(10) Collection description: Under the Railroad Retirement Act, the Railroad Retirement Board administers the Medicare program for persons covered by the railroad retirement system. The collection obtains the information needed to determine if certain railroad beneficiaries are entitled to receive Supplementary Medical Insurance program coverage under a state buy-in agreement in states in which they reside.

Additional Information or Comments

Copies of the forms and supporting documents can be obtained from Charles Mierzwa, the agency clearance officer (312-751-3363).

Comments regarding the information collection should be addressed to Ronald J. Hodapp, Railroad Retirement Board, 844 North Rush Street, Chicago, Illinois, 60611-2092 and to the OMB Desk Officer for the RRB, at the Office of Management and Budget, Room 10230, New Executive Office Building, Washington, DC 20503.

Charles Mierzwa,

Clearance Officer.

[FR Doc. 04-25290 Filed 11-12-04; 8:45 am]