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Open Season Health Benefits Enrollment Change Form

IC 33686 under ICR 199610-3206-004 · OMB 3206-0200.

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Open Season Health Benefits Enrollment Change Form
 
No Migrated
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form OPM-2809-EZ2 Yes Yes


    

35,345 0
   
Individuals or Households
 
   18 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 35,345 0 0 0 0 35,345
Annual IC Time Burden (Hours) 17,672 0 0 0 0 17,672
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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