Information Collection

TRICARE Retiree Dental Program Enrollment Appication

IC 5586 under ICR 200708-0720-003 · OMB 0720-0015.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0015 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Delta Dental Form TRICARE Retiree Dental Program Enrollment Appication	Form
Delta Dental Form TRICARE Retiree Dental Program Enrollment Application Dental Form.pdf	Form

IC Title:

TRICARE Retiree Dental Program Enrollment Appication

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 32 CFR 199.22

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	Delta Dental Form	TRICARE Retiree Dental Program Enrollment Application	Dental Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 71,332

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 25 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	71,332	21,332	50,000
Annual IC Time Burden (Hours)	17,833	10,333	7,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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