Information Collection

Form 13560 - HCTC Health Plan Administrator (HPA) Return of Funds Form

IC 19574 under ICR 202010-1545-008 · OMB 1545-1891.

Documents and Forms

Document Name Document Type
Form 13560 Form 13560 - HCTC Health Plan Administrator (HPA) Return of Funds Form Form and Instruction
13560 Health Plan Administrator (HPA) Return of Funds f13560--2017-05-00.pdf Form and Instruction
13560 Health Plan Administrator (HPA) Return of Funds f13560--2017-05-00.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Form 13560 - HCTC Health Plan Administrator (HPA) Return of Funds 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	13560	Health Plan Administrator (HPA) Return of Funds	f13560--2017-05-00.pdf		Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	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.