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Affordable Care Act Enrollment Opportunity Notice Relating to Extension of Dependent Coverage
Affordable Care Act Enrollment Opportunity Notice Relating to Extension of Dependent Coverage
OMB: 1210-0139
IC ID: 192671
OMB.report
DOL/EBSA
OMB 1210-0139
ICR 201011-1210-003
IC 192671
( )
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
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:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
29 CFR 2590.715-2714(f)
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Federal Enterprise Architecture Business Reference Module
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:
Businesses or other for-profits, Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
38 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
79,573,000
0
0
0
0
79,573,000
Annual IC Time Burden (Hours)
411,000
0
0
0
0
411,000
Annual IC Cost Burden (Dollars)
1,233,500
0
0
0
0
1,233,500
Documents for IC
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.