Form 14116 - HCTC - Family Member Eligibility Form

Forms and Documents

Document Name	Status
Form 14116 HCTC - Family Member Eligibility Form (Form 14116) Form	New
ombat2.doc Supplementary Document	2009-11-03
Supporting Statement for HCTC Family Member Eligibility Form.pdf Supporting Statement A	2009-11-03

IC Document Collections

IC ID	Document Title	Status
191172	HCTC - Family Member Eligibility Form (Form 14116) Form	New

ICR Details

OMB Control No: 1545-2163	ICR Reference No: 200911-1545-005
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: TREAS/IRS	Agency Tracking No: Response requested by 11/24/09
Title: Form 14116 - HCTC - Family Member Eligibility 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: 11/24/2009
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/15/2009
	Date Received in OIRA: 11/06/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2010	6 Months From Approved
Responses	180	0	0
Time Burden (Hours)	30	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This form will be used by the family members of Health Coverage Tax Credit (HCTC) eligible individuals under circumstances where the original candidate has died or become divorced from the family member. This form allows family member to begin the HCTC registration process by verifying the family member’s eligibility.

Emergency Justfication: The Health Coverage Improvement, Section 1899E of the ARRA authorizes the continuation of HCTC benefits for qualified family members after the original HCTC candidate has been canceled from the program due to Medicare enrollment. These forms must be made available to taxpayers before the end of this year.

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Authorizing Statute(s): US Code: 26 USC 35 Name of Law: Health insurance costs of eligible individuals
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 5 1899E 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
HCTC - Family Member Eligibility Form (Form 14116)	14116	Family Member Eligibility 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	180	0	180	0	0	0
Annual Time Burden (Hours)	30	0	30	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: The Health Coverage Improvement, Section 1899E of the ARRA authorizes the continuation of HCTC benefits for qualified family members after the original HCTC candidate has been canceled from the program due to Medicare enrollment. These forms must be made available to taxpayers before the end of this year. The creation of this form will increase the estimated number of responses by 180 and the total burden by 30 hours.

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Annual Cost to Federal Government: $20

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: 11/06/2009

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