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:

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 %

	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.