SS Form 14116 REV

SUPPORTING STATEMENT
1. CIRCUMSTANCES NECESSITATING COLLECTION OF INFORMATION
The Health Coverage Improvement, Section 1899E of the ARRA authorizes the continuation of HCTC benefits for
qualified family members after the original HCTC candidate experiences death or divorce. The family member will
complete this form in order to verify the event that made them eligible for the HCTC.

2. USE OF DATA
The information provided by the respondent will be used to verify family member’s eligibility for the HCTC program.

3. USE OF IMPROVED INFORMATION TECHNOLOGY TO REDUCE BURDEN
There are no plans at this time to provide electronic filing.

4. EFFORTS TO IDENTIFY DUPLICATION
Respondents will be asked to provide demographic information to identify themselves. This information will be
captured in the registration system and will be searchable to avoid duplication.

5. METHODS TO MINIMIZE BURDEN ON SMALL BUSINESSES OR OTHER SMALL ENTITIES
N/A- The Family Member Eligibility Form does not collect information from small businesses.

6. CONSEQUENCES OF LESS FREQUENT COLLECTION ON FEDERAL PROGRAMS OR
POLICY ACTIVITIES
Without collecting the information requested in the form, the HCTC program will have no way to verify the eligibility of
the family members.

Form 14029 (Rev. 4-2009) Catalog Number 51944B Page 4

Department of the Treasury–Internal Revenue Service

7. SPECIAL CIRCUMSTANCES REQUIRING DATA COLLECTION TO BE INCONSISTENT
WITH GUIDELINES IN 5 CFR 1320.5(d)(2)
N/A.

8. CONSULTATION WITH INDIVIDUALS OUTSIDE OF THE AGENCY ON AVAILABILITY
OF DATA, FREQUENCY OF COLLECTION, CLARITY OF INSTRUCTIONS AND FORMS,
AND DATA ELEMENTS
Periodic meetings are held between IRS personnel and representatives of the American Bar Association, the National
Society of Public Accountants, the American Institute of Certified Public Accountants, and other professional groups to
discuss tax law and tax forms. During these meetings, there is an opportunity for those attending to make comments
regarding the HCTC registration form for Medicare family members.
In response to the Federal Register notice (75 FR 5873), dated February 4, 2010, we received no comments during
the comment period regarding Form 14116.

9. EXPLANATION OF DECISION TO PROVIDE ANY PAYMENT OR GIFT TO RESPONDENTS
N/A

10. ASSURANCE OF CONFIDENTIALITY OF RESPONSES
Generally, tax returns and tax return information are confidential as required by 26 USC 6103.

11. JUSTIFICATION OF SENSITIVE QUESTIONS
The Family Member Eligibility Form requests limited sensitive information about the original HCTC candidate and
family members solely for the purpose of verifying eligibility.

12. ESTIMATED BURDEN OF INFORMATION COLLECTION
List the number of responses, time per response, and total burden for each form included in the submission.
The burden estimate is as follows:
Number of
Time per
Total
Responses
Response
Hours
HCTC registration form

180

10 mins.

30

Estimates of the annualized cost to respondents for the hour burdens shown are not available at this time.

Form 14029 (Rev. 4-2009) Catalog Number 51944B

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Department of the Treasury–Internal Revenue Service

13. ESTIMATED TOTAL ANNUAL COST BURDEN TO RESPONDENTS
As suggested by OMB, our Federal Register notice dated February 4, 2010, requested public comments on estimates
of cost burden that are not captured in the estimates of burden hours, i.e., estimates of capital or start-up costs and
costs of operation, maintenance, and purchase of services to provide information. However, we did not receive any
response from taxpayers on this subject. As a result, estimates of the cost burdens are not available at this time.

14. ESTIMATED ANNUALIZED COST TO THE FEDERAL GOVERNMENT
No additional equipment will be needed, there will be minimal printing needs for this form given the number of
anticipated respondents. Estimate cost is about $20 annually (assuming order of 1,000 forms at 2 cents a form).

15. REASONS FOR CHANGE IN BURDEN
There are no changes to the burden estimates previously approved by OMB. This submission is for renewal purposes
only.

16. PLANS FOR TABULATION, STATISTICAL ANALYSIS AND PUBLICATION
N/A.

17. REASONS WHY DISPLAYING THE OMB EXPIRATION DATE IS INAPPROPRIATE
See attached.

18. EXCEPTIONS TO THE CERTIFICATION STATEMENT ON OMB PRA SUBMISSION FORM
Not applicable.
Note: The following paragraph applies to all of the collections of information in this submission:
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless
the collection of information displays a valid OMB control number. Books or records relating to a collection of
information must be retained as long as their contents may become material in the administration of any internal
revenue law. Generally, tax returns and tax return information are confidential, as required by 26 U.S.C. 6103.

19. REASON FOR EMERGENCY SUBMISSION

Form 14029 (Rev. 4-2009) Catalog Number 51944B

Page 6

Department of the Treasury–Internal Revenue Service