Health Coverage Tax Credit Registration Form

ICR 200308-1545-040

OMB: 1545-1842

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
41158 Migrated
ICR Details
1545-1842 200308-1545-040
Historical Active 200305-1545-055
TREAS/IRS
Health Coverage Tax Credit Registration Form
No material or nonsubstantive change to a currently approved collection   No
Emergency 08/27/2003
Approved without change 08/27/2003
Retrieve Notice of Action (NOA) 08/27/2003
  Inventory as of this Action Requested Previously Approved
11/30/2003 11/30/2003 11/30/2003
156,000 0 156,000
78,000 0 78,000
0 0 0

Form 13441, Health Coverage Tax Credit Registration Form, will be used for a pilot conducted between 5/19/03 and 7/31/03 in one to two states to help a limited population of individuals determine if they are eligible for the Health Coverage Tax Credit and enable them to register for the pilot HCTC program. Participation in this pilot is voluntary. This form will be submitted by the individual to the HCTC program office ina postage-paid, return envelope. We will accept faxed forms, if necessary. Addionally, recipients may call the HCTC call center for help in completing this form.

None
None


No

1
IC Title Form No. Form Name
Health Coverage Tax Credit Registration Form 13441

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 156,000 156,000 0 0 0 0
Annual Time Burden (Hours) 78,000 78,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
08/27/2003


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