Information Collection

Payment of Pemiums (29 CFR Part 2610) and Forms/Instructions Thereunder

IC 121634 under ICR 199502-1212-003 · OMB 1212-0009.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1212-0009 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Payment of Pemiums (29 CFR Part 2610) and Forms/Instructions Thereunder	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.	Available Electronically?	Can Be Submitted Electronically?
Form	FORM-1-ES	No	No
Form	FORM-1	No	No
Form	SCHEDULE-A-TO-	No	No
Form	FORM-1	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 62,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	70,500	70,500	0
Annual IC Time Burden (Hours)	86,160	0	86,160
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.