Information Collection

Revenue Procedure 2004-12, Health Insurance Costs of Eligible Individuals

IC 19544 under ICR 200401-1545-007 · OMB 1545-1875.

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Information Collection (IC) Details

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IC Title:	Revenue Procedure 2004-12, Health Insurance Costs of Eligible Individuals	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

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

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	26	26
Annual IC Cost Burden (Dollars)	0	0

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