1545-XXXX Supporting Statement

SUPPORTING STATEMENT
1. CIRCUMSTANCES NECESSITATING COLLECTION OF INFORMATION
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.

2. USE OF DATA
The information provided by the respondent will be used to determine the amount for the retroactive payment to be
made to the participant for monthly premiums paid prior to the commencement of advance payment of the federal tax
credit.

3. USE OF IMPROVED INFORMATION TECHNOLOGY TO REDUCE BURDEN
The reimbursement request form will be posted to the HCTC website allowing respondents to download the form
directly.

4. EFFORTS TO IDENTIFY DUPLICATION
Respondents submitting reimbursement will be asked to specify months during the calendar year for which they are
requesting retroactive payment and will be asked to submit supporting documents for each month. Payment history is
recorded in HCTC's customer relationship management system to avoid duplication of payments.

5. METHODS TO MINIMIZE BURDEN ON SMALL BUSINESSES OR OTHER SMALL ENTITIES
N/A- The reimbursement form does not collect information from small businesses

6. CONSEQUENCES OF LESS FREQUENT COLLECTION ON FEDERAL PROGRAMS OR
POLICY ACTIVITIES
Section 1899B authorizes individuals to request retroactive payments. Without collecting the information request 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.

Form 14029 (Rev. 4-2009) Catalog Number 51944B Page 4

Department of the Treasury–Internal Revenue Service

7. SPECIAL CIRCUMSTANCES REQUIRING DATA COLLECTION TO BE INCONSISTENT
WITH GUIDELINES IN 5 CFR 1320.5(d)(2)
N/A.

8. CONSULTATION WITH INDIVIDUALS OUTSIDE OF THE AGENCY ON AVAILABILITY
OF DATA, FREQUENCY OF COLLECTION, CLARITY OF INSTRUCTIONS AND FORMS,
AND DATA ELEMENTS
Periodic meetings are held between IRS personnel and representatives of the American Bar Association, the
National Society of Public Accountants, the American Institute of Certified Public Accountants, and other
professional groups to discuss tax law and tax forms. During these meetings, there is an opportunity for those
attending to make comments regarding Form 8900.
We will publish a notice in the Federal Register in the near future to solicit public comments on the HCTC
Reinbursement form.

9. EXPLANATION OF DECISION TO PROVIDE ANY PAYMENT OR GIFT TO RESPONDENTS
Retroactive payments will be made to eligible individuals for months occuring prior to the first month for which an
advance payment is made on behalf of eligible individual.

10. ASSURANCE OF CONFIDENTIALITY OF RESPONSES
The reimbursement request form contains the following section, "PRIVACY ACT STATEMENT. The follwoing
information is provided to comply with the Privacy Act of 1974 (P.L.93-579)."

11. JUSTIFICATION OF SENSITIVE QUESTIONS
The reimbursement request form requestes limited sensitive information regarding health plan coverage and qualified
family members solely for the purpose of processing retroactive payments.

12. ESTIMATED BURDEN OF INFORMATION COLLECTION
It is estimated the reimbursement request form will be used by 3,058 respondents one time annually. The total number
of hours estimated for respondents is 1,529 annually. For support staff, the total estimated number of burden hours is
510 to process the forms for the 3,058 respondents annually. Respondents for the reimbursement request are from an
unemployed population, therefore it is estimated that there is no cost for their time.

Form 14029 (Rev. 4-2009) Catalog Number 51944B

Page 5

Department of the Treasury–Internal Revenue Service

13. ESTIMATED TOTAL ANNUAL COST BURDEN TO RESPONDENTS
Estimates of capital or start-up costs and costs of operation, maintenance, and purchase of services to provide
information are not available at this time.

14. ESTIMATED ANNUALIZED COST TO THE FEDERAL GOVERNMENT
No additional equipment will be needed, and there will be minimal printing costs as the primary method for distribution
of the form will be to download it from the HCTC website.

15. REASONS FOR CHANGE IN BURDEN
This is a new form.

16. PLANS FOR TABULATION, STATISTICAL ANALYSIS AND PUBLICATION
N/A

17. REASONS WHY DISPLAYING THE OMB EXPIRATION DATE IS INAPPROPRIATE
See attached.

18. EXCEPTIONS TO THE CERTIFICATION STATEMENT ON OMB PRA SUBMISSION FORM
N/A.
Note: The following paragraph applies to all of the collections of information in this submission:
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless the collection of information displays a valid OMB control number. Books or records relating to a collection of
information must be retained as long as their contents may become material in the administration of any internal
revenue law. Generally, tax returns and tax return information are confidential, as required by 26 U.S.C. 6103.

19. REASON FOR EMERGENCY SUBMISSION
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.

Form 14029 (Rev. 4-2009) Catalog Number 51944B

Page 6

Department of the Treasury–Internal Revenue Service