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Federal forms, ICRs, and supporting documents

Information Collection Request

The Health Coverage Tax Credit (HCTC) Reimbursement Request Form

ICR 202111-1545-022 · OMB 1545-2152 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form 14095 The Health Coverage Tax Credit (HCTC) Reimbursement Request Form Form and Instruction Modified Repair queued
SS 1545-2152_2021.docx Supporting Statement A Uploaded 2022-02-18 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
190222 The Health Coverage Tax Credit (HCTC) Reimbursement Request Form Form and Instruction Modified
ICR Details
1545-2152 202111-1545-022
Received in OIRA 201802-1545-011
TREAS/IRS
The Health Coverage Tax Credit (HCTC) Reimbursement Request Form
Revision of a currently approved collection   No
Regular 02/28/2022
  Requested Previously Approved
36 Months From Approved 02/28/2022
3,416 3,058
2,278 2,039
0 0
This form is used by HCTC participants to request reimbursement for health plan premiums paid prior to the commencement of advance payments.
PL: Pub.L. 111 - 5 1899B Name of Law: American Recovery and Reinvestment Act of 2009
  
None
Not associated with rulemaking
  86 FR 68042 11/30/2021
87 FR 10896 02/25/2022
No
  Total Request 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 3,416 3,058 0 0 358 0
Annual Time Burden (Hours) 2,278 2,039 0 0 239 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
There are no changes to the form at this time, however the agency has updated the number of responses based on most recent filing data. There has been an estimated increase of 358 responses (3,058 to 3,416), resulting in an overall hourly burden increase of 239 hours (2039 to 2278).
$0
No
    Yes
    Yes
Yes
No
Yes
No
Tiffany Haskell 737 800-7633
  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.
02/28/2022