OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Form - 14117 - HCTC Medicare Family Member Registration Form

ICR 201006-1545-022 · OMB 1545-2162 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form 14117 HCTC Medicare Family Member Registration Form Form and Instruction Modified Repair queued
ombat2.doc Supplementary Document Uploaded 2009-11-03 Available
Supporting Statement for HCTC Registration Form for Medicare Family Members.pdf Supporting Statement A Uploaded 2010-06-07 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
191173 HCTC Medicare Family Member Registration Form Form and Instruction Modified
ICR Details
1545-2162 201006-1545-022
Historical Active 200911-1545-006
TREAS/IRS
Form - 14117 - HCTC Medicare Family Member Registration Form
Extension without change of a currently approved collection   No
Regular
Approved without change 08/25/2010
Retrieve Notice of Action (NOA) 06/25/2010
  Inventory as of this Action Requested Previously Approved
08/31/2013 36 Months From Approved 08/31/2010
2,400 0 2,400
1,200 0 1,200
0 0 0
The Health Coverage Improvement, Section 1899E of the ARRA authorizes the continuation of HCTC benefits for qualified family members after the original HCTC candidate has been canceled from the program due to Medicare enrollment. The original HCTC candidate will complete this form in order to continue enrollment for or to register their family members in the monthly HCTC program.
US Code: 26 USC 35 Name of Law: Health insurance costs of eligible individuals
   PL: Pub.L. 111 - 5 1899E Name of Law: American Recovery and Reinvestment Act 2009
  
None
Not associated with rulemaking
  75 FR 5870 02/04/2010
75 FR 36473 06/25/2010
No
1
IC Title Form No. Form Name
HCTC Medicare Family Member Registration Form 14117 HCTC Family Member Registration
  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 2,400 2,400 0 0 0 0
Annual Time Burden (Hours) 1,200 1,200 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$225
No
No
No
Uncollected
Yes
Uncollected
Lynn Reno 2022839639
  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.
06/25/2010