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TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request
TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request
OMB: 0720-0028
IC ID: 5604
OMB.report
DOD/DODOASHA
OMB 0720-0028
ICR 200506-0720-002
IC 5604
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0028 can be found here:
2024-06-27 - Revision of a currently approved collection
2021-04-27 - Extension without change of a currently approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request
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-2853
No
No
Form
DD-2854
No
No
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
14,289
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
14,289
0
0
-6,400
0
20,689
Annual IC Time Burden (Hours)
1,536
0
0
-614
0
2,150
Annual IC Cost Burden (Dollars)
0
0
0
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.