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Federal forms, ICRs, and supporting documents

Information Collection Request

Revenue Procedure 2004-12, Health Insurance Costs of Eligible Individuals

ICR 200404-1545-043 · OMB 1545-1875 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
19545 Revenue Procedure 2004-12, Health Insurance Costs of Eligible Individuals Migrated
ICR Details
1545-1875 200404-1545-043
Historical Active 200401-1545-007
TREAS/IRS
Revenue Procedure 2004-12, Health Insurance Costs of Eligible Individuals
Extension without change of a currently approved collection   No
Regular
Approved without change 05/28/2004
Retrieve Notice of Action (NOA) 04/28/2004
  Inventory as of this Action Requested Previously Approved
05/31/2007 05/31/2007 07/31/2004
51 0 51
26 0 26
0 0 0
Revenue Procedure 2004-12 informs states how to elect a health program to be qualified health insurance for purposes of the health coverage tax credit (HCTC) under section 35 of the Internal Revenue Code. The collection of information is voluntary. However, if a state does not make an election, eligible residents of the state may be impeded in their efforts to claim the HCTC.
None
None
No
1
IC Title Form No. Form Name
Revenue Procedure 2004-12, Health Insurance Costs of Eligible Individuals
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 51 51 0 0 0 0
Annual Time Burden (Hours) 26 26 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
04/28/2004