Information Collection

Carrier's Report of Issuance of Policy

IC 190307 under ICR 201412-1240-004 · OMB 1240-0004.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0004 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Carrier's Report of Issuance of Policy	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR CFR 703.116 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: n/a	FR Citation: 67 FR 16886

Number of Respondents: 360	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 98 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5,000	0	5,000
Annual IC Time Burden (Hours)	83	0	83
Annual IC Cost Burden (Dollars)	2,088	-562	2,650

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