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Federal forms, ICRs, and supporting documents

Information Collection Request

Form 13560, HCTC Health Plan Administrator (HPA) Return of Funds Form, and Form 13561, HCTC Health Plan Administrators Operations Guide

ICR 200410-1545-017 · OMB 1545-1891 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
19574 Form 13560, HCTC Health Plan Administrator (HPA) Return of Funds Form, and Form 13561, HCTC Health Plan Administrators Operations Guide Form Migrated
ICR Details
1545-1891 200410-1545-017
Historical Active 200406-1545-030
TREAS/IRS
Form 13560, HCTC Health Plan Administrator (HPA) Return of Funds Form, and Form 13561, HCTC Health Plan Administrators Operations Guide
Extension without change of a currently approved collection   No
Regular
Approved without change 12/02/2004
Retrieve Notice of Action (NOA) 10/27/2004
  Inventory as of this Action Requested Previously Approved
12/31/2007 12/31/2007 12/31/2004
200 0 200
50 0 50
0 0 0
Form 13560 is completed by Health Plan Administrators (HPAs) and accompanies a return of funds in order to ensure proper handling. This form serves as supporting documentations for any funds returned by an HPA and clarifies where the payment should be applied and why it is being sent. Form 13561 will be provided in the HCTC (Health Coverage Tax Credit) Health Plan Administrator Operations Guide. Form 13561 is an evaluation form intended to gather feedback from HPAs on the quality of the HCTC HPA Registration and Operations Guides.
None
None
No
1
IC Title Form No. Form Name
Form 13560, HCTC Health Plan Administrator (HPA) Return of Funds Form, and Form 13561, HCTC Health Plan Administrators Operations Guide 13560, 13561
  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 200 200 0 0 0 0
Annual Time Burden (Hours) 50 50 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.
10/27/2004