Information Collection

Questionnaire - Medical And Dental Expenses

IC 129726 under ICR 198301-1545-012 · OMB 1545-0335.

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Information Collection (IC) Details

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IC Title:	QUESTIONNAIRE - MEDICAL AND DENTAL EXPENSES	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	4742				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 125,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	125,000	125,000
Annual IC Time Burden (Hours)	62,500	62,500
Annual IC Cost Burden (Dollars)	0	0

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.