Information Collection

Certificates for Health Care Benefits

IC 20365 under ICR 200303-1615-064 · OMB 1615-0062.

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Certificates for Health Care Benefits	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

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 21,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	21,000	21,000
Annual IC Time Burden (Hours)	37,240	37,240
Annual IC Cost Burden (Dollars)	4,550,000	4,550,000

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.