Information Collection

HCTC Medicare Family Member Registration Form

IC 191173 under ICR 201308-1545-008 · OMB 1545-2162.

Documents and Forms

Document Name Document Type
Form 14117 HCTC Medicare Family Member Registration Form Form and Instruction
14117 HCTC Family Member Registration Form14117_OCT2012.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HCTC Medicare Family Member Registration Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Form and Instruction	14117	HCTC Family Member Registration	Form14117_OCT2012.pdf		Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,400	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,400	0	2,400
Annual IC Time Burden (Hours)	600	-600	1,200
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.