Distributions from an Archer MSA or Medicare+Choice MSA

ICR 200403-1545-042

OMB: 1545-1517

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
40848 Migrated
ICR Details
1545-1517 200403-1545-042
Historical Active 200209-1545-001
TREAS/IRS
Distributions from an Archer MSA or Medicare+Choice MSA
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 03/17/2004
Retrieve Notice of Action (NOA) 03/17/2004
  Inventory as of this Action Requested Previously Approved
11/30/2005 11/30/2005 10/31/2005
25,839 0 25,839
3,618 0 3,618
0 0 0

This form is used to report distributions from a medical savings account as set forth in section 220(h).

None
None


No

1
IC Title Form No. Form Name
Distributions from an Archer MSA or Medicare+Choice MSA 1099-SA

  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 25,839 25,839 0 0 0 0
Annual Time Burden (Hours) 3,618 3,618 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.
03/17/2004


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