Information Collection

Third-Party Collection Program, Insurance Information

IC 5376 under ICR 199705-0704-001 · OMB 0704-0323.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0704-0323 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

Third-Party Collection Program, Insurance Information

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	DD-2569				Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 74,224

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	74,224	74,224
Annual IC Time Burden (Hours)	3,043	3,043
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

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