HCTC Medicare Family Member Registration Form

HCTC Medicare Family Member Registration Form

OMB: 1545-2162

IC ID: 191173

Documents and Forms
Document Name
Document Type
Other-Draft form
Information Collection (IC) Details

View Information Collection (IC)

HCTC Medicare Family Member Registration Form
 
No New
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Draft form HCTC Registration Form for Medicare Family Members 102809.doc Yes No Fillable Printable

General Government Taxation Management

 

2,400 0
   
Individuals or Households
 
   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 2,400 2,400 0 0 0 0
Annual IC Time Burden (Hours) 1,200 1,200 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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