Information Collection

Employer's Agreement, Annual Cost Projection Statement, Statistical Compensation Statement, Annual Cost Projection & Fiscal Year End Cost Statement

IC 112753 under ICR 197710-0938-005 · OMB 0938-0066.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0066 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	EMPLOYER'S AGREEMENT, ANNUAL COST PROJECTION STATEMENT, STATISTICAL COMPENSATION STATEMENT, ANNUAL COST PROJECTION & FISCAL YEAR END COST STATEMENT	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	HCFA-9777C,	No	No
Form	9778,9779	No	No
Form	9780	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,000	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	3,910	3,910
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

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