Information Collection

Model Employer CHIP Notice

IC 191695 under ICR 201001-1210-001 · OMB 1210-0137.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0137 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Model Employer CHIP Notice1-2010.doc	Other-Model Employer CHIP Notice

IC Title:

Model Employer CHIP Notice

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

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
Other-Model Employer CHIP Notice			Model Employer CHIP Notice1-2010.doc		Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,056,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 38 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	203,795,000	203,795,000
Annual IC Time Burden (Hours)	1,053,000	1,053,000
Annual IC Cost Burden (Dollars)	25,271,000	25,271,000

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.