Information Collection

Notice Relating to Extension of Dependent Coverage - State and Local gov't plans

IC 192838 under ICR 201005-0938-002 · OMB 0938-1089.

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IC Title:

Notice Relating to Extension of Dependent Coverage - State and Local gov't plans

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 147.120

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 126,000

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	19,627,000	19,627,000
Annual IC Time Burden (Hours)	202,812	202,812
Annual IC Cost Burden (Dollars)	0	0

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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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