Information Collection

HCTC Medicare Family Member Registration Form

IC 191173 under ICR 201006-1545-022 · OMB 1545-2162.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-2162 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 14117 HCTC Medicare Family Member Registration Form	Form and Instruction
14117 HCTC Family Member Registration Form and Instruction.pdf	Form and Instruction

IC Title:

HCTC Medicare Family Member Registration Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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
Form and Instruction	14117	HCTC Family Member Registration	Form and Instruction.pdf		Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,400	2,400
Annual IC Time Burden (Hours)	1,200	1,200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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