Information Collection

Open Season Health Benefits Enrollment Change Form or Request for Additional Information

IC 33687 under ICR 199610-3206-003 · OMB 3206-0201.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3206-0201 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Open Season Health Benefits Enrollment Change Form or Request for Additional Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	2809-EZ1				Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 74,200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 5 %

	Approved	Previously Approved
Annual Number of Responses for this IC	74,200	74,200
Annual IC Time Burden (Hours)	37,100	37,100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

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