OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Form - 14117 - HCTC Medicare Family Member Registration Form

ICR 201308-1545-008 · OMB 1545-2162 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form 14117 HCTC Medicare Family Member Registration Form Form and Instruction Modified Available
ombat2.doc Supplementary Document Uploaded 2009-11-03 Available
Supporting_Statement_for_HCTC_Registration_Form_for_Medicare_Family_Members_AUG2013].pdf Supporting Statement A Uploaded 2013-08-29 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
191173 HCTC Medicare Family Member Registration Form Form and Instruction Modified
ICR Details
1545-2162 201308-1545-008
Historical Active 201006-1545-022
TREAS/IRS
Form - 14117 - HCTC Medicare Family Member Registration Form
Revision of a currently approved collection   No
Regular
Approved without change 11/26/2013
Retrieve Notice of Action (NOA) 08/29/2013
  Inventory as of this Action Requested Previously Approved
11/30/2016 36 Months From Approved 11/30/2013
2,400 0 2,400
600 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.
PL: Pub.L. 111 - 5 1899E Name of Law: American Recovery and Reinvestment Act 2009
   US Code: 26 USC 35 Name of Law: Health insurance costs of eligible individuals
  
None
Not associated with rulemaking
  78 FR 9453 02/08/2013
78 FR 52822 08/26/2013
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) 600 1,200 0 0 -600 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
An adjustment of 600 burden hours is realized to correct the response time previously reported at 30 mins. to 15 mins. to coordinate with that which is reported on the Form 14117. Total burden hours requested is 600.
$225
No
No
No
No
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.
08/29/2013