The Health Coverage Tax Credit (HCTC) Reimbursement Request Form

Forms and Documents

Document Name	Status
Form HCTC The Health Coverage Tax Credit (HCTC) Reimbursement Request Form Form and Instruction	New
ombat2.doc Supplementary Document	2009-08-07
1545-XXXX Supporting Statement.pdf Supporting Statement A	2009-08-07

IC Document Collections

IC ID	Document Title	Status
190222	The Health Coverage Tax Credit (HCTC) Reimbursement Request Form Form and Instruction	New

ICR Details

OMB Control No: 1545-2152	ICR Reference No: 200908-1545-006
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: TREAS/IRS	Agency Tracking No: Need approval by 8/13 - ARRA request
Title: The Health Coverage Tax Credit (HCTC) Reimbursement Request Form
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 08/13/2009
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/11/2009
	Date Received in OIRA: 08/10/2009
Terms of Clearance: This collection is approved with the following terms of clearance: This collection is approved as an emergency clearance to meet ARRA requirements. This collection will be valid for six months. If the agency decides to continue to use this collection past the approved emergency request clearance time period, it must resubmit to OMB under the normal PRA review process for a three year approval.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2010	6 Months From Approved
Responses	3,058	0	0
Time Burden (Hours)	2,039	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This form will be used by HCTC participants to request reimbursement for health plan premiums paid prior to the commencement of advance payments.

Emergency Justfication: As part of the ARRA changes relating to the Health Coverage Improvement, Section 1899B authorizes that retroactive payments be made to eligible individuals for months occurring prior to the first month for which and advance payment is made on behalf of the eligible individual. Taxpayers need the form to comply with the guidance (to be issued 8/14/09), and receive reimbursement as outlined by the law. Without collecting the information requested on the reimbursement form, the HCTC will have no way of knowing how much and for what months the individual may request retroactive payments for.

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Authorizing Statute(s): PL: Pub.L. 111 - 5 1899B Name of Law: American Recovery and Reinvestment Act of 2009
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 5 1899B Name of Law: American Recovery and Reinvestment Act of 2009

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
The Health Coverage Tax Credit (HCTC) Reimbursement Request Form	HCTC	The Health Coverage Tax Credit (HCTC) Reimbursement Request Form

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ICR Summary of Burden

	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	3,058	0	3,058	0	0	0
Annual Time Burden (Hours)	2,039	0	2,039	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: As part of the ARRA changes relating to the Health Coverage Improvement, Section 1899B authorizes that retroactive payments be made to eligibile individuals for months occuring prior to the first month for which and advance payment is made on behalf of the eligibile individual. The effect of these changes to the Health Coverage Improvement results in an increase in responses by 3,058 and a total burden increase of 2,039 hours.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Yes

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 08/10/2009

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