Health Coverage Tax Credit Registration Form

Forms and Documents

Document Name	Status
Form 13441 Health Coverage Tax Credit Registration Form Form and Instruction	Unchanged
Form 13441-EZ Monthly HCTC (Health Coverage Tax Credit) Group Registration Form Form and Instruction	New
Summary of Changes.pdf Justification for No Material/Nonsubstantive Change	2010-04-08

IC Document Collections

IC ID	Document Title	Status
41159	Health Coverage Tax Credit Registration Form Form and Instruction	Unchanged
192496	Monthly HCTC (Health Coverage Tax Credit) Group Registration Form Form and Instruction	New

ICR Details

OMB Control No: 1545-1842	ICR Reference No: 201004-1545-001
Status: Historical Active	Previous ICR Reference No: 200909-1545-001
Agency/Subagency: TREAS/IRS	Agency Tracking No:
Title: Health Coverage Tax Credit Registration Form
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/04/2010
	Date Received in OIRA: 05/13/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2013	02/28/2013	02/28/2013
Responses	5,400	0	1,800
Time Burden (Hours)	1,800	0	900
Cost Burden (Dollars)	0	0	0

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Abstract: Form 13441, Health Coverage Tax Credit Registration Form, will be directly mailed to all individuals who are potentially eligible for the HCTC. Potentially eligible individuals will use this form to determine if they are eligible for the Health Coverage Tax Credit and to register for the HCTC program. Participation in this program is voluntary. This form will be submitted by the individual to the HCTC program office in a postage-paid, return envelope. We will accept faxed forms, if necessary. Additionally, recipients may call center for help in completing this form.

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Authorizing Statute(s): PL: Pub.L. 107 - 210 116 Stat. 933 Name of Law: The Trade Act of 2002
   US Code: 26 USC 35 Name of Law: Health insurance costs of eligible individuals
  

Citations for New Statutory Requirements: None

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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
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 31088	06/29/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 58073	11/10/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Monthly HCTC (Health Coverage Tax Credit) Group Registration Form	13441-EZ	Monthly HCTC (Health Coverage Tax Credit) Group Registration Form
Health Coverage Tax Credit Registration Form	13441	Health Coverage Tax Credit

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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	5,400	1,800	0	3,600	0	0
Annual Time Burden (Hours)	1,800	900	0	900	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Form 13441 is used to determine if taxpayers are eligible for the Health Coverage Tax Credit and to register for the HCTC program. Form 13441-EZ is a simplified version of Form 13441 and will be used for a streamlined batch process to register groups of individuals for the monthly HCTC Program. The creation of the new form 13441-EZ will result in an increase in the number of responses by 3,600 and a total of 900 burden hours.

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Annual Cost to Federal Government: $65,000

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]? No

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)? No

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: 05/13/2010

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