Information Collection

Internal Revenue Service/social Security Administration Health Care Financing Administration Data Match Projct (42 Usc 1395y(b)(5))

IC 113988 under ICR 199108-0938-012 · OMB 0938-0565.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0565 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	INTERNAL REVENUE SERVICE/SOCIAL SECURITY ADMINISTRATION HEALTH CARE FINANCING ADMINISTRATION DATA MATCH PROJCT (42 USC 1395Y(B)(5))	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-R-137				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,100,000	0	1,100,000
Annual IC Time Burden (Hours)	3,293,450	-189,883	3,483,333
Annual IC Cost Burden (Dollars)	0	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.