Information Collection

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

IC 192671 under ICR 201005-1210-001 · OMB 1210-0139.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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Document Name	Document Type

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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:

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: 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 %

table that charts list of burden
	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

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.