Information Collection

Continued Health Care Benefit Program (CHCBP) Application

IC 5413 under ICR 200205-0704-004 · OMB 0704-0364.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0704-0364 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Continued Health Care Benefit Program (CHCBP) Application	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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	DD-2837				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 808	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	808	208	600
Annual IC Time Burden (Hours)	202	52	150
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.