05-11871. 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: Application for Reimbursement for Hospital Services in Canada.

(2) Form(s) submitted: AA-104.

(3) OMB Number: 3220-0086.

(4) Expiration date of current OMB clearance: 07/31/2005.

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

(6) Respondents: Individuals or households.

(7) Estimated annual number of respondents: 50.

(8) Total annual responses: 50.

(9) Total annual reporting hours: 8.

(10) Collection description: The Railroad Retirement Board administers the Medicare program for persons covered by the Railroad Retirement system. The collection obtains the information needed to determine eligibility and for the amount due for covered hospital services received in Canada.

FOR FURTHER INFORMATION CONTACT:

Copies of the forms and supporting documents can be obtained from Charles Mierzwa, the agency clearance officer ([phone]) or [e-mail].

Comments regarding the information collection should be addressed to Ronald J. Hodapp, Railroad Retirement Board, 844 North Rush Street, Chicago, Illinois 60611-2092 or [e-mail] 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.