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Federal forms, ICRs, and supporting documents

Information Collection Request

Form 8453-R - Declaration and Signature for Electronic Filing of Forms 8947 and 8963

ICR 201702-1545-012 · OMB 1545-2253 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form 8453-R Form 8453-R - Declaration and Signature for Electronic Filing of Forms 8947 and 8963 Form and Instruction Modified Available
SUP STAT (Form 8453-R) 2017.docx Supporting Statement A Uploaded 2017-03-09 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
210086 Form 8453-R - Declaration and Signature for Electronic Filing of Forms 8947 and 8963 Form and Instruction Modified
ICR Details
1545-2253 201702-1545-012
Historical Active 201401-1545-018
TREAS/IRS
Form 8453-R - Declaration and Signature for Electronic Filing of Forms 8947 and 8963
Extension without change of a currently approved collection   No
Regular
Approved without change 06/16/2017
Retrieve Notice of Action (NOA) 03/28/2017
  Inventory as of this Action Requested Previously Approved
06/30/2020 36 Months From Approved 06/30/2017
2,550 0 2,550
4,131 0 4,131
0 0 0
Use Form 8453-R to authenticate the electronic filing of Form 8947, Report of Branded Prescription Drug Information, and Form 8963, Report of Health Insurance Provider Information.
PL: Pub.L. 111 - 152 1406 Name of Law: Health Care and Education Reconciliation Act of 2010
   PL: Pub.L. 111 - 148 9010 Name of Law: Patient Protection and Affordable Care Act (PPACA)
  
PL: Pub.L. 111 - 148 9010 Name of Law: Patient Protection and Affordable Care Act (PPACA)
PL: Pub.L. 111 - 152 1406 Name of Law: Health Care and Education Reconciliation Act of 2010
Not associated with rulemaking
  81 FR 83332 11/21/2016
82 FR 15419 03/28/2017
No
  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 2,550 2,550 0 0 0 0
Annual Time Burden (Hours) 4,131 4,131 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$150
No
No
Yes
No
No
Uncollected
Philip Beram 202 317-5999
  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.
03/28/2017