Information Collection

Affordable Care Act Enrollment Opportunity Notice Relating to Extension of Dependent Coverage

IC 192671 under ICR 201004-1210-008 · OMB 1210-0139.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0139 can be found here:

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Information Collection (IC) Details

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IC Title:	Affordable Care Act Enrollment Opportunity Notice Relating to Extension of Dependent Coverage	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 29 CFR 2590.715-2714(f)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,800,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 38 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	79,573,000	79,573,000
Annual IC Time Burden (Hours)	411,000	411,000
Annual IC Cost Burden (Dollars)	1,233,500	1,233,500

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