Information Collection

Application and Renewal for Health Benefits

IC 28251 under ICR 200402-2900-007 · OMB 2900-0091.

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Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

Application and Renewal for Health Benefits

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-10EZ				Yes	Yes
Form	10-10EZR				Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,900,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 1 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,900,000	-1,142,687	-2,942,313	5,985,000
Annual IC Time Burden (Hours)	1,005,000	-461,667	-1,188,750	2,655,417
Annual IC Cost Burden (Dollars)	0	0	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.